A Clinical Study on the Efficacy of Homeopathic Remedies in Bleeding Haemorrhoids
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A Clinical study on the Efficacy of Homeopathic Remedies in Bleeding Haemorrhoids
Dr. Thanka.R
Acknowledgement “Ex nihilo nihil fit” out of nothing, nothing comes except Him, the Alpha and the Omega, the Prime Mover, who is the sum and substance of every being. It is He who has ordained me to part take of the divine task of the healing power. The physician prescribes the medicine but He administers the healing. I offer my very being in thanks giving to the Almighty for making me add my simple string to the divine lute of curing through this work of mine.
Next to God, I would like to thank my mother and father for enabling me to become a drop in the ocean of the mystery and the miracle of Homoeopathic practice and contribute my own little might to the saga of Homoeopathic theory and practice through this maiden work.
Without a devoted teacher no disciple ever achieved anything. A sincere teacher moulds the mettle and calibre of the students given to her care. I render my heartfelt gratitude and sincere appreciation to my teacher and guide Dr. Aleyamma Thomas, without whose timely guidance, scholarly deliberations and patient discussions, my work would not have been successfully completed.
I would like to extend my sincere thanks to Dr. Abdul Rahman, the Principal, Government Homoeopathic Medical College, Thiruvananthapuram for his overall supervision.
A special word of appreciation and gratitude to Dr.Jaya, the Superintendent, Government Homoeopathic Medical College Hospital, Thiruvananthapuram for her guidance and support.
My cordial thanks to Dr. Nisha Paul, Professor and Head of the Department of Organon of Medicine and Homoeopathic Philosophy for encouraging and enlightening me throughout my work.
I owe my special thanks to all the faculty of the Department of Organon of Medicine and Homoeopathic Philosophy for their stimulating suggestions and priceless opinions during the course of my study.
I thank Dr. Muraleedharan from the depth of my heart for his rarest inspiration and for unraveling the mystery and matrix of Homoeopathy which helped me to accomplish my work.
For the generous and magnanimous gesture of permission and co-operation exercised by the Management, the Principal and the Faculty of Sarada Krishna Homoeopathic Medical College, Kulasekharam, I offer them my immense gratitude. 1
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I also owe my indebtedness to the teaching and non teaching staff of Government Homoeopathic Medical College, Thiruvananthapuram for what they had been to me during my research work.
I deem it a great privilege to offer my heart felt appreciation to all my well wishers, friends, the senior and junior P.Gs for their motivation and interaction which added to my knowledge and skill throughout the period of my study.
A physician is like a fish out of water without his patients. They are the Promised Land where he can successfully experiment therapeutic power. I record my all consuming gratitude for their patient co-operation and interaction.
LIST OF DIAGRAMS 1. Protomodel of constitution of Henry .E. Sigerist 2. Kinder’s protomodel of temperament 3. Rectum and anal canal 4. Anus showing subcutaneous muscles 5. Anus showing conjoined longitudinal and corrugator cutis ani 6. Anal papillae, crypts and margagnian coloumns 7. Different layers of rectal wall 8. Houston’s valves 9. Coronal section showing anorectal muscles 10. Intermuscular sulcus 11. Blood supply to anorectal area 12. Nervous supply 13. Defecation reflex 14. Stages of Haemorrhoids 15. Figure showing differential diagnosis 16. Rubber band ligation
LIST OF COLOUR PLATES 1. Anal Canal-General 2. Digital rectal examination –position and methods 3. Different types of Proctoscope 4. Conditions of differential diagnosis 5. Rubber band ligation 6. Ferguson technique 7. Harmonic Scalpel Haemorrhoidectomy 8. Stapled Haemorrhoidectomy 9. Haemorrhoids
LIST OF TABLES 1. Haemorrhoidectomy-Atomizing vs. the CO2 laser 2. Miasmatic representation of rectal symptoms 2
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3. Repertorial representation of Haemorrhoids 4. Medicines of Repertorial analysis 5. Parameters for disease criteria for treatment assessment 6. Demographic tables of prevalence of Haemorrhoids in this study 7. Statistical analysis table 8. Master table of 30 cases 9. Medicines used in this study 10. Proforma case record
LIST OF GRAPHS I. Showing socio demographic characters of the study group 1. distribution according to age 2. distribution according to sex 3. distribution according to occupation 4. distribution according to economic class 5. distribution according to family history of piles & other diseases 6. distribution according to educational status 7. distribution according to clinical presentation 8. distribution according to predominant miasm II. Showing the effectiveness of treatment 1. distribution according to changes in symptoms 2. distribution according to different medicines used
“The physician who is the most successful is he who will first heal for the love of healing who will practice first for the purpose of verifying his knowledge and performing this use for the love of it.”
“The perfecting of our science in this new century is becoming an increasingly sad and gloomy business; without professional liberality and friendliness it will continue to be a science for bunglers for another full century.” SAMUEL HAHNEMANN (1755-1843)
Every age witnessed the emergence of valiant sages in the different realms of philosophy, literature, arts, science, medicine and treatment. These men were singularly imbued with God- sent intuitive power to challenge and change the existing out moded thoughts and practices. In the field of medicine, also there was born a Messiah instilled with an indomitable spirit for a silent revolution to continue with nature’s preservative and curative power in a miraculous way by altering drastically to the shreds the then existing system of medicine so as to alleviate and mitigate the excruciating sufferings of humanity with a new amazing power of healing practice. That apostle assigned by God with this new vision and mission was Dr. Friedrich Samuel Hahnemann.
The maxim “ man is the product of heredity , upbringing , time , and his environment” bears testimony to the life of our founder father Samuel Hahnemann who waged a single handed and relentless battle against the existing ritualistic way of mere treatment and took it on to the 3
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philanthropic plane of healing where he catered to the mental and emotional matrix of a living being and engendered a unique system of treatment protecting the best interest of humanity.
The Homoeopathic system of medicine sprouted from this great man’s impeccable observation, infallible interpretation, rational explanation and scientific construction of simple unknown principle of nature’s law of cure- ‘similia similibus curentur.’ In this noble and lofty system, diseases are treated according to the symptom similarity with single medicine in minute dose which results in rapid, gentle and permanent cure.
Every advancement and progress ushered in the field of science and technology was also reflected verily in the realm of modern medicine with its materialistic approach in health, disease and treatment. Sophisticated machines and methods were introduced for the diagnosis and treatment of diseases. This paved the way for the rapid rise of humpty number of specialists, who conceived the system of healing part by part or organ by organ. This resulted in an unprecedented progress of surgery which became the ultimate level of treatment of modern medicine. In surgery, diseases are treated merely as local affection and their removal as cure. But the remission and recurrence of the same disease or its altered form often revealed that such treatment was mere suppression where the internal morbid state existed unabated and smothered. This was foreseen and foretold by far sighted Hahnemann 200 years before. Now the modern medicine itself accepts this dynamic conceptual force of Hahnemann as the truth.
Haemorrhoids is one such disease which challenges the modern treatment namely local medication and surgical removal. Half the population suffers from this disease with bleeding, pain, itching, prolapse or altered bowel habits. This causes extreme inconvenience which hurdles and hinders the patient’s daily routine with great mental agony and anxiety.
Haemorrhoids caused Napoleon to sit side- saddle, sent President Jimmy Carter to the operating room, and benched baseball star George Brett during the 1980 World Series. Over two thirds of all healthy people reporting for physical examinations have haemorrhoids. Unfortunately a haemorrhoidal condition only tends to get worse over the years, never better.
The concept of Ayurveda regarding Haemorrhoids states that it is one among the eight “Maha vyadis” of medicine, obstinate for management because of recurrence and prolonged suffering. They consider their origin to the fault in the “Tridoshas”- the vatha, pitha and kabha. The terminology in use is “Arshas”. They can be of sushka (non-bleeding) and ardra (bleeding) varieties. Regarding the aetiology, the concept is intertwined with the habit of bowel movement (constipation- ‘udavartham’). To the question of treatment it is listed under “Yapyam”- only manageable and not curable.
In Homoeopathy, Haemorrhoids are treated as not local but as derangement in the dynamic vital force that are expressed out through signs and symptoms of bleeding, pain, itching and prolapse and are corrected only by means of dynamic medicines, which are capable of producing artificial similar diseases in healthy individuals, in a safe, gentle and effective manner.
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As man is prior to his organs so is the derangement of vital force to the development of tissue changes. These tissue changes are the result of disease. These local tissue changes are not the disease but only the external manifestation of the disease on the material body which stem forth from the internal dynamic derangement of the vital force. Through this dynamic derangement, the man is affected in totum which rationally demands a constitutional management for the extirpation of the illness in its entirely leading to a permanent restoration of health which inevitably wards off its recurrence and transference to the progeny and this can be achieved only through the symptomatic individualistic antimiasmatic constitutional treatment administered by Homoeopathic system.
Under these circumstances it is decided to conduct a clinical study to evaluate the effectiveness of constitutional medicine in the management of bleeding Haemorrhoids. The detailed methodology and plan of action are discussed in the concerned section and the results are statistically analyzed to derive evident conclusions.
The present study has been ventured by me to verify the efficacy of constitutional management in bleeding Haemorrhoids emboldent by the statement made by Dr. Samuel Hahnemann in his Materia Medica Pura-
“This doctrine appeals solely to the verdict of experience. Repeat the experiments , it cries aloud , repeat them carefully and accurately , and you will find the doctrine confirmed at every step ; and it does what no medical doctrine , no system of physic ,no so- called therapeutics ever did or could do- it insists upon being judged by results.”
To study the effectiveness of Constitutional Medicines in the treatment of Bleeding Haemorrhoids.
To verify statistically the results of the study through the analysis of clinical symptoms before and after treatment.
REVIEW OF LITERATURE General concept of health Homoeopathic perspective of disease Constitution and constitutional medicine Anatomy of rectum and anal canal Physiology of defecation Haemorrhoids
Concept of Health and Factors Affecting It - Health - Modern Concept
World Health Organization (W.H.O-1984) defines, “Health is a state of complete physical, mental and social well being and not merely an absence of disease or infirmity.” 5
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Operational definition of Health by W.H.O – “Health is a condition or quality of the human organism expressing the adequate functioning of the organism in given conditions, genetic or environmental.”
Positive health – it implies the notion of perfect health in body and mind. It cannot become a reality, it always remain a mirage because everything in our life is subject to change.
Dimensions of health - Health is multidimensional- mainly physical, mental and social (Also spiritual, emotional, vocational, political, cultural, socio-economic, environmental, philosophical, educational, nutritional, curative and preventive dimensions).
Physical dimension – it implies the notion of “perfect functioning” of the body. A good complexion, clean skin, bright eyes, firm flesh, not too fat, a sweet breath, good appetite, sound sleep, regular activity of bowels and bladder and co-coordinated bodily movements. All organs are of unexceptional size and functions normally, all intact special senses, normal pulse rate, blood pressure and exercise tolerance.
Mental dimension – mental health is not mere absence of mental illness. A mentally healthy person is one who is free from internal conflicts, well adjusted ( i.e. able to get along well with others and he accepts criticism and is not easily upset), searches for identity, a firm sense of self esteem, knows himself ( his needs, problems and goals), good self control and faces problems and tries solve them intelligently.
Social dimension – it implies harmony and integration with in the individual, between each individual and other member of the society and between individuals and the world in which they live.
Spiritual dimension – it refers to that part of individual which reaches out and strives for meaning and purpose in life.
Emotional dimension – mental health can be seen as ‘knowing’ or ‘cognition’ while emotional health relates to ‘feeling’.
Vocational dimension – it’s a new dimension of life. It refers to mental and physical adaptation to work (human goals, capacities and limitations).
Determinants of health - Health is multifactorial. Determinants of health are - 1. Heredity- the genetic make up is unique and cannot be altered after conception. A number of diseases like chromosomal abnormalities, errors of metabolism, mental retardation, some types of diabetes are of genetic origin.
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2. Environmental- the “internal” environment of man pertains to every tissue, organ, organ- system, parts and their harmonious functioning. The “external” environment pertains to all that is external to the human host. 3. Life style-the way people live. It composed of cultural and behavioral patterns and life long personal habits (smoking, alcoholism etc) that have developed through the processes of socialization. 4 Socio-economic conditions – the health status is determined primarily by socioeconomic development. Important socioeconomic factors are; a) Economic status: the economic progress is the major factor in reducing morbidity, increasing life expectancy & improving quality of life. b) Educational status: second major factor influencing health is education. Literacy coincides with poverty, malnutrition, ill health, high infant and child mortality rates. c) Occupation: unemployed people usually show higher incidence of ill health and death. It can cause psychological and social damage.
5. Health Services – it helps in the treatment of disease, prevention of illness and promotion of health.
Ecology of health - Ecology is defined as the science of mutual relationship between living organisms and their ecology. Health according to ecological concept is a state of dynamic equilibrium between man and his environment. Prevention of disease through ecological or environmental manipulations or interventions is safer, cheaper and a more effective rational approach. It is through environmental manipulations that disease such as cholera, typhoid, malaria etc. are brought under control or eliminated.
Indicators of health - Indicators of health are used to measure the health status of a community and also to compare the health status of one country to another. They are as follows, 1. Mortality indicator 7. Indicator of social and mental health 2. Morbidity indicator 8. Environmental indicators 3. Disability rates 9. Socio-economic indicators 4. Nutritional status indicator 10. Health policy indicators 5. Health care delivery indicator 11. Indicators of quality of life 6. Utilization rates 12. Other indicators
FACTORS AFFECTING HEALTH— Modern concept 1. Germ theory of disease: - This theory emphasis microbe as the sole cause of disease. But its demerit is that it cannot explain the multifactorial disease conditions.
2. Epidemiological triad: - It is a triad of environment, agent and host
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3. Multifactorial causation: - multiple factors are responsible for a disease, i.e. microbes, physical, mental, social, economic, genetic and psychological factor. e.g., coronary heart diseases, lung cancer, c/c bronchitis etc.
4. Web of causation: - This model is ideally suited in the study of c/c diseases where the disease agent is often not known, but is the outcome of interaction of multiple factors.
5. Agent factor: – Defined as a substance, living or non living, or a force, tangible or intangible, the excessive presence or relative lack of which may initiate or perpetuate a disease process. They are –
1. Biological agents-- Living agents of disease, viz. bacteria, viruses, rickettsiae, fungi, protozoa and metazoa. 2. Nutrient agents – The excess or deficiency of proteins, fats, vitamins, minerals and water may results in nutritional disorders. 3. Physical agents – exposure to excessive heat, cold, humidity, pressure, radiation, electricity, sound, etc may result in illness . 4. Chemical agents – i) Endogenous: i.e., formed in the body as a result of derangement of functions. E.g. urea (uremia), bilirubin (jaundice), etc… ii) Exogenous; agents outside the human host. E.g. Allergens, metals, fumes, dust, insecticides, etc. 5. Mechanical agents – sprains, dislocations, c/c friction, etc… 6. Absence or insufficiency or excess of factor necessary to health –these may be i) Chemical factors e.g. Hormone ii) Nutrient factors iii) Lack of structure iv) Lack of part of structure, v) Chromosomal factors e.g. Turner’s syndrome vi) Immunological factors e.g. Agammaglobulinaemia.
7. Social agents – these are poverty, smoking, abuse of drug and alcohol, social isolation, maternal deprivation etc.
6. Host factor (intrinsic) - host is ‘soil’ and disease agent is ‘seed’. It includes age, sex, ethnicity; biological characteristics such as genetic factors, blood groups, etc; socio-economic factors such as status, education, occupation, stress, etc and life style such as personality traits, drugs, alcohol, smoking behavior patterns etc.
7. Environmental factors (extrinsic) - it is complex and all-embracing. Defined as all that which is external to individual human host, living and non living and with which he is in constant interaction. Environment of man is divided into three components – physical, biological and psychological.
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8. Risk factors- defined as an attribute or exposure that is significantly associated with the development of the disease. Risk factors are often suggestive, i.e. presence of a risk factor does not imply that the disease will occur, and in its absence diseases will not occur. Risk factors may be causative (e.g., smoking for CA lung), contributory (lack of physical exercise for CHD) or predictive (e.g., illiteracy for prenatal mortality).
HEALTH – HOMOEOPATHIC CONCEPT Science is nothing but formulated and systematized knowledge with principles and laws. And the practical application of any science is called an art. So science and art are inseparably bound together. Every art has its foundation in science and every science finds its expression in art. Homoeopathy is both an art and science as it rests on immutable law “similia similibus curentur –let likes be cured by likes.”
Dr. Samuel Hahnemann was a great philanthropist. His life and works reveals his quest and zest for a divine therapeutic system for the removal of disease and preservation of health. In the introduction of The Friend of Health (1792) Hahnemann says – “My mission is only to preach upon the greatest of corporeal blessings – health i.e. regarding the rational care about the health.”
Homoeopathy is infact the crown of the medicine of all times, which sprang from the infallible and intuitive genius and acumen of Hahnemann, the world’s most renowned founder father of this miraculous curative system. His summum bonum is the unending health and happiness of mankind. To assure this he delved deep into the prime matter and substantial form of every diseased individual unlike the existing practice of medicine which are merely concerned with diagnosis of disease.
Homoeopathy is based on the principles of the Inductive Method of Science. Its practice is governed by the principle of Symptom-Similarity, which is the application in medicine of the universal principle of Mutual Action formulated by Sir Isaac Newton in his Third Law of Motion: "Action and reaction are equal and opposite." Homœopathy, as a science, rests fundamentally upon four general principles: Similarity, Contrariety, Proportionality and Infinitesimality, reducible to the universal principle of Homœosis, or Universal Assimilation. (Fincke)
Organon of Medicine is the clinical manifesto of Dr. Samuel Hahnemann, containing the concept of health, disease and its cure, the postulate of Homoeopathic philosophy which expounds the diverse dimensions of health in terms of vital force.
In 9th aphorism (Organon of Medicine 5th edition) - “In the healthy condition of man, the spiritual vital force (autocracy), the dynamis that animates the material body (organism), rules with unbounded sway, and retains all the parts of the organism in admirable, harmonious, vital operation, as regards both sensations and functions, so that our indwelling, reason-gifted mind can freely employ this living healthy instrument for the higher purposes of our existence”. i.e., in health all the vital operations are going on harmoniously 9
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where vital force is the supreme power, which animates and rules providing normal sensations and functions. In 10th aphorism (Organon of Medicine 5th edition) “The material, organism without vital force, is capable of no sensation, no function, no self preservation; it derives all sensation and functions of life solely by means of the immaterial being (the vital force) which animates the material organism in health and in disease.” Thus as per Dr.Hahnemann ‘spiritual health’ is prior to all the other dimensions of health namely physical, mental and social.
Physician’s mission and health - In 1st aphorism (Organon of Medicine 5th edition) he says “the physician’s high and only mission is to restore the sick to health.” Beside a therapeutist, physician has other functions also, like diagnostician, a prognosticator, a preventive and public health officer and a medico-legal jurist as well. But the chief duty is concerned with curing the sick i.e., to restore the sick to health.
Ideal cure and health- In 2nd aphorism (Organon of Medicine 5th edition) he says “the cure must be rapid, gentle and permanent i.e., removal of disease in it whole extent, in shortest, most reliable and most harmless way on easily comprehensible principles.” Cure should be affected in the most harmless way- harmless to the patient, to his bystanders and to the society. We can see a lot of examples of it, from the old school medicine to the modern medicine. Thus in the treatment level also health has got prim importance.
Cause of the disease or factors affecting health-The 5th aphorism (Organon of Medicine 5th edition) deals with it. In acute disease the exciting cause and in chronic disease the fundamental cause i.e. the chronic miasm. For this the physical constitution of the patient, his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, age, sexual functions etc are to be taken into consideration.
“The man wills and understands. The cadaver does not will and understand. Then that which takes its departure is that which knows and wills. It is that which can be changed prior to the body. The combination of these too, the will and understanding constitute man. ; Conjoined they make life and activity; they manufacture the body and cause all things of the body. With the will and understanding operating in order we have a healthy man. This is the spiritual health. When the man wills well, he enjoys good physical, mental and social health.”
H.A.Roberts says, “In order to obtain a thorough knowledge of these vital functions we must study them in their manifestations during health. From the earliest period of its existence growth is manifest from within the cell out; it is never observed growing from without in. The one point most vital to observe is the course and direction of its expression- always from within outward. This is true in the embryonic state and is always maintained as long as life exists. This is equally true in the specialization of functions. The especial organs are developed and their functions maintained by the expression of the vital energy as the life-giving principle. All expressions of the mind are such manifestations. Indeed, it is the expression of the 10
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vital force in and through the mind and intellect that has a very great influence in the functioning of all life and of the special organs. In health all expressions of vital force may be expressed by perfect functioning of all parts of the body and by a sense of general well-being.”
According to Stuart close, “health is the balanced condition of living organism in which the integral harmonious performance of the vital functions tends to the preservation of the organism and the normal development of the individual. A healthy man, who lives in a favorable environment moves, feels, thinks acts and reacts in an orderly manner. But when he becomes the victim of an unfavorable environment, deterioration of health is the result. Life is the invisible, substantial, intelligent, individual, co-ordinating power and cause directing and controlling the forces involved in the production and activity of any organism possessing individuality.”
"Power resides at the center, and from the center of power, force flows." The phenomena of life, as manifested in growth, nutrition, repair, secretion, excretion, self-recognition, self-preservation and reproduction, all take their direction from an originating center. From the lowest cell to the highest and most complex organism, this principle holds true. Cell wall and protoplasmic contents develop from the central nucleus and that from the centrosome, which is regarded as the "center of force" in the cell. All fluids, tissues and organs develop from the cell from within outwards, from center to circumference.
Organic control is from the center. In the completely developed human organism vital action is controlled from the central nervous system. The activities of the cell are controlled from, the centrosome, which may be called the brain of the cell. The central nervous system may be compared to a dynamo. As a dynamo is a machine, driven by steam or some other force, which, through the agency of electro-magnetic induction from a surrounding magnetic field, converts into electrical energy in the form of current the -mechanical energy expended upon it, so the central nervous system is a machine driven by chemical force derived from food which, through the agency of electro-vital induction from a surrounding vital field, converts into vital energy, in the form of nerve current or impulses, the chemico-physical energy expended upon it.
As an electrical transportation system depends for its working force upon the dynamo located in its central power station, so the human body depends for the force necessary to carry on its operations upon the central power station, located in the central nervous system. Any disturbance of conditions at the central power station is immediately manifested externally at some point in the system; and any injury to or break in the external system is immediately reflected back to the central station.
In health and disease it is the same, both being essentially merely conditions of life in the living organism, convertible each into the other. In each condition the modifying agent or factor acts primarily upon the internal life principle, which is the living substance of the organism. This reacts and produces external phenomena through the medium of the brain and nervous system which, extends to every part of the body. Food or poison, toxins or antitoxins, 11
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therapeutic agents or pathogenic micro-organisms, all acts upon and by virtue of be existence of the reacting life principle or living substance of the organism.
Cure of disease, or the restoration of health, likewise begins at the center and spreads outwardly, the symptoms disappearing from within outward, from above downward and in the reverse order of their appearance.
Resistance to morbific agents is from the center where life reigns. Vital resistance is the defensive reaction of living substance to noxious elements and organisms and to disease-producing causes and agents in general, in obedience to the inherent instinct or law of self-preservation, which belongs to life in organism.
Strictly speaking, it is not against disease that we struggle, but against the causes of disease - the actual causes of disease. They do not exist in the life substance itself. They become operative or effective in the organism conditionally, by virtue of the existence of the vital principle of susceptibility, reaction and resistance, and of a living organism in and through which action and reaction can take place.
The human organism works as a totality always, whether performing its normal functions or defending itself from morbific stimuli in an integrated state of three levels of hierarchy –the mental plane, emotional plane and the physical plane. The mental level of being is the most crucial for the individual’s existence and maintains within itself a hierarchy very useful for evaluating the progress of the patient. A healthy mind should be characterized in its functions from the following three qualities-clarity, coherence and creativity. The emotional plane of the human being is next to importance to the mental plane. If the individual is free from passions such as negative feelings like jealousy, anguishness, sadness etc, then he can be healthy on this plane. The physical body and its organs constitute the least importance plane of the human being; the body also maintains a hierarchy of importance as to its organs and functions.
In this way health can be defined as follows, “health is freedom from pain in the physical body, having attained a state of well-being; freedom from passion on the emotional level, having as a result a dynamic state of serenity and calm; and freedom from selfishness in the mental sphere, having as a result total unification with Truth.”
When these three planes of human existence are expressed in three dimensions, the mental plane comes as the centre, the emotional plane as the next peripheral envelope, and the physical plane as the outermost covering. At any given moment, the center of gravity will tend to rest at a particular location. It may move higher or lower on the same plane or it may move centrally or more peripherally to higher or lower levels of correspondence. The three factors that cause the changes in the center of gravity are hereditary strength or weakness of the defense mechanism, intensity of the morbific stimuli and degree of interference by the suppressive treatments.
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Health and susceptibility -In aphorisms 30, 31 & 32 of Organon of medicine 5th edition, our master Dr.Samuel Hahnemann explains the susceptibility in relation to health, disease and cure. “The human body appears to admit of being much more powerfully affected in its health by medicines (partly because we have the regulation of the dose in our own power) than by natural morbid stimuli- for natural diseases are cured and overcome by suitable medicines.”
“The inimical forces, partly psychical, partly physical, to which our terrestrial existence is exposed, which are termed morbific noxious agents, do not possess the power of morbidly deranging the health of man unconditionally; but we are made ill by them only when our organism is sufficiently disposed and susceptible to the attack of the morbific cause that may be present and to be altered in its health, deranged and made to undergo abnormal sensations and functions- hence they do not produce disease in every one, nor at all times.”
“But it is quite otherwise with the artificial morbific agents which we term medicines. Every real medicine, namely, acts at all times, under all circumstances, on every living human being, and produces in him its peculiar symptoms (distinctly perceptible if the dose be large enough), so that evidently every human organism is liable to be effected, and, as it were, inoculated with the medical disease, at all times and absolutely (unconditionally), which, as before said, is by no means the case with the natural disease.”
According to Dr. Stuart Close, “susceptibility is the general quality or capability of the living organism of receiving impressions; the power to react to stimuli. Susceptibility is one of the fundamental attributes of life. In health- Upon it depends all functioning, all vital processes, physiological and pathological. Digestion, assimilation, nutrition, repair, secretion, excretion, metabolism and catabolism, as well as all disease processes arising from infection or contagion depend upon the power of the organism to react to specific stimuli.” The cure and alleviation of diseases depend upon the same power of the organism to react to the impression of the curative remedy. When we give a drug to a healthy person for the purpose of making a Homoeopathic "proving" or test, the train of symptoms which follows represents the reaction of the susceptible organism to the specific irritant or stimulus administered. When a homoeopathically selected medicine is administered to a sick person, the disappearance of the symptoms and restoration of the patient to health represents the reaction of the susceptible organism to the impression of the curative remedy.
"Susceptibility in organism, mental or bodily, is equivalent to state, which involves the attitude of organizations to internal causes and to external circumstances. It is all the resource of defense or the way of yielding. "In health we live and act and resist without knowing it. In disease we live but suffer; and know ourselves in conscious or unconscious exaggeration."
We must also predicate a state of normal susceptibility to remedial as well as toxic agencies, which it is the duty of the physician to conserve and utilize. No agent or procedure should be used as a therapeutic measure which has the power to, diminish, break 13
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down or destroy the normal susceptibility or reactibility of the organism, because that is one of the most valuable medical assets we possess. Without it all our efforts to cure are in vain. To use agents in such a manner or in such a form or quantity as to diminish, impair or destroy the power of the organism to react to stimuli, is to align ourselves with the forces of death and disintegration. Conservation of the power of the organism to react defensively to a toxin, a contagion, or an infection is as important as it is to conserve the power to react constructively to food and drink, or curatively to the homoeopathic remedy. It is as normal and necessary for the organism to react pathogenetically to a poison, in proportion to the size and power of the dose, as it is to react physiologically to a good dinner.
According to H.A.Roberts, We may define susceptibility primarily as the reaction of the organism to external and internal influences. In analyzing susceptibility, we find it is very largely an expression of a vacuum in the individual. This is illustrated by the desire for food. The vacuum attracts and pulls for the things most needed, that are on the same plane of vibration as the want in the body. Susceptibility varies in degree in different patients, and at different times in the same patient. Susceptibility can be increased, diminished or destroyed. It therefore becomes a state of lowered resistance or attraction.
It is incumbent upon us to recognize, conserve and utilize normal susceptibility, to physical environments, to foods, to remedies and to toxic agencies. It should be our aim never to use any agent or anything of any nature, or to adopt any procedure, that would in the least diminish or destroy this power of susceptibility and the reaction of the organism in its normal manner. The status of health depends upon this normal susceptibility and reaction. It is just as much the province of the physician to exercise conservation of susceptibility in the organism that it may act defensively against a toxin, contagion or infection, as it is to have this susceptibility react constructively to food and drink or to the curative remedy. Again, it is just as natural and important for the organism to react pathogenically to the size and power of a dose of poison as it is for it to react to the demand for food. The human economy has inherited many tendencies from the accumulations of its ancestral heritage. This tendency of human economies is brought out still further by the susceptibilities of whole families towards certain types of diseases. This again is governed by the law of susceptibility because they are similar to the constitutional condition. Thus we see that susceptibility and reactions are the basic principles and are very closely allied to the problems of immunization. The similar remedy, or the similar disease, satisfies susceptibility and establishes immunity.
Health and drug proving - In the aspect of proving also health has got prime importance, because in Homoeopathy drug are proved in healthy human beings. Aphorisms 105 to 145 of Organon of Medicine 5th edition, are dealing with drug proving. Proving in lower animals will not give exact symptoms, especially the subjective symptoms; also their body is different from that of man. Proving in sick persons will give you the mixed symptoms of disease and the drug.
In Aphorism 108, “There is, therefore, no other possible way in which the peculiar effects of medicines on the health of individuals can be accurately ascertained - there is 14
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no sure, no more natural way of accomplishing this object, than to administer the several medicines experimentally, in moderate doses, to healthy persons, in order to ascertain what changes, symptoms and signs of their influence each individually produces on the health of the body and of the mind; that is to say, what disease elements they are able and tend to produce, since, as has been demonstrated (Aphorism 24-27), all the curative power of medicines lies in this power they possess of changing the state of man's health, and is revealed by observation of the latter”. Before Hahnemann, Albrecht von Haller was the only man who mentioned about it.
Three essential things for proving- 1. The quality of the drug must be pure, 2.The prover must possess the proper balance in functions and be in a normal, healthy state, so that we can estimate and weigh the amount of the disturbance caused when we deliberately upset the balance of health. 3. The circumstances surrounding the prover must be those of his normal surroundings. The ordinary habits of life must be observed, and his ordinary work maintained; otherwise changes from his routine might cause some deviation from his normal balance which would be attributed to the drug action.
Qualities of prover - The prover must be intelligent enough properly to appreciate and record the subjective symptoms as deviations from his normal conditions of life, as these subjective symptoms are of the utmost value. Honesty is a prerequisite of a good prover, for he must be very careful to record all phenomena as fact. Remember always to treat a fact as a fact and do not try to add to or subtract from its importance; it is not for the prover to sift the symptoms produced. At the beginning of this work, the prover must be in that state of mental, moral and physical equilibrium that is characteristic of a normal, healthy being. One who is subject to rapidly changing equilibrium on any one or all of these planes will not make a good prover.
Homoeopathic physician and preserver of health - Prevention is better than cure is a truism. 4th Aphorism deals with the social and preventive medicine. “He is like wise a preserver of health if he knows the things that deranges health and cause disease and how to remove them from persons in health”
The cause of disease is internal (chronic miasm), but many of the disturbances that aggravate the disorder are external (e.g. - improperly selected food, living in damp cellars etc.). These are the measures that disturbing him, making him sick and aggravating his chronic miasm, i.e. things “which keep up disease”. Any ordinary physician with a well knowledge in hygiene can remove these external obstacles and preserve his patient’s health.
In the book, “The Friend of Health” published in 1792, we can see how seriously and comprehensively Hahnemann wished to see all questions of health and public hygiene treated even in the earlier years of his activity. Hahnemann deals with Social and individual hygiene during his time.
· Hahnemann gives exact and very strict instructions for the public care of health in infectious and contagious diseases. 15
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Hahnemann gives hygienic advices for those who visit the sick, to the physician & nurses (for avoiding infection in dangerous fever and contagious diseases). His consultations by letter consist almost entirely of advices concerning hygiene and diet. Avoid overcrowding of the prisoners in a single room without proper ventilation and prison should be thoroughly cleaned and disinfected. Regarding children’s health, he describes the circumstances of town life in relation to upbringing of children. A special attention on women’s dressings- Discouraging tight clothing, tight lacing and the mischief done by wearing corsets. Importance of Exercise: - He recommends gradual hardening of the body. Exercise and good air alone set all the humours in our body in motion to fill their appointed places, and compel every secreting organs to give off its specific secretions, give power to the muscles and deposits red colour to the blood, helps to refine the fluids so that they penetrate easily into the most minute capillary vessels, strengthen the heart beats and brings about healthy digestion. He condemns strongly things that pollute air.
Genus epidemicus and Preventive medicine-In Organon of Medicine, aphorisms 100 and 101deal with epidemics and Genus epidemicus. The concept of genus epidemics was first practically applied by Samuel Hahnemann. “I found same remedy given at the period when the symptoms indicative of invasion of the diseases occurs, stifles the fever in its very birth”- Cure and prevention of Scarlet Fever (1801). He gave Belladonna for the prevention and prophylaxis for scarlet fever and Veratrum alb & camphor for Asiatic cholera.
Now a day the prevailing epidemics are recurring and new ones are attacking mankind. Here the question of individual immunity arises. Thus along with the improvement of hygienic measures we have to conserve the individual immunity- by avoiding suppressive treatment and by proper mode of living. So in our modern era Hahnemann’s concept of prevention & hygiene has got great value.
Considering the situation of the medical field during Hahnemann’s period it is astonishing to see his courage and insight in this field. He was filled with anxiety in the first instance on account of the continual outbreaks of contagious diseases, but he was actuated by love for all his fellow beings, particularly the poor, the needy and helpless. The pioneering efforts in the field of public hygiene must be especially emphasized.
Conclusion The modern concept of factors affecting health deals with germ theory of disease, epidemiological triad, multifactorial causation, web of causation, agent factor, environmental factors (extrinsic) and the host factor (intrinsic). In which they give most importance to agent factor i.e., biological agents like bacteria, viruses, rickettsiae, fungi, protozoa and metazoa. They give less importance to physical, chemical, mechanical, nutrient and social agents and least importance to host factor. Host is ‘soil’ and disease agent is ‘seed’. According to modern concept the host factors includes age, sex, genetic factors, blood groups,
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socio-economic factors such as status, education, occupation, stress and life style such as personality traits, drugs, alcohol, smoking behavior patterns etc. In Homoeopathy, the factors affecting health includes- in acute disease the exiting cause and in chronic diseases the fundamental cause i.e., chronic miasm. For this the physical constitution of the patient, his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, age, sexual functions etc are to be taken into consideration.. It is not against disease that we struggle, but against the causes of disease - the actual causes of disease. They do not exist in the life substance itself. They become operative or effective in the organism conditionally, by virtue of the existence of the vital principle of susceptibility, reaction and resistance, and of a living organism in and through which action and reaction can take place. Homoeopathy offers ideal cure- rapid, gentle and permanent cure in harmless way- i.e., not suppression or palliation.
So Homoeopathic concept of health is superior to that of modern concept in all means, because here the host factor is most important. The modern concept of health - ‘a state of complete physical, mental and social well being and not merely an absence of disease or infirmity’ is not a new one. It was first explained by Dr.Samuel Hahnemann through his wholistic approach in the therapeutics and its proof is Homoeopathy. Homoeopathy is a system of therapeutics, based on fixed and concrete principles, in which the ultimate aim is to achieve health. It is different from the modern medicine because it views human beings as individual, not as a machine. Wholistic approach- i.e., treating patients as a whole, not the diseased parts. Cure must be rapid, gentile and permanent but above all the method used must be most harmless one, i.e., in every aspect of homoeopathic treatment health has got prime importance.
HOMOEOPATHIC PERSPECTIVE OF DISEASE Dr. Hahnemann’s conception of disease is of dynamic origin when he writes further in continuation with §9, in §11(Organon of Medicine 5th Edition) “When a person falls ill, it is only this spiritual, self acting (automatic) vital force, everywhere present in his organism, that is primarily deranged by the dynamic influence upon it of a morbific agent inimical to life; it is only the vital force, deranged to such an abnormal state, that can furnish the organism with its disagreeable sensations, and incline it to the irregular processes which we call disease”. Dr. Hahnemann defines diseases in §19 (Organon of Medicine 5th Edition), as “diseases are nothing more than alterations in the state of health of the healthy individual which express themselves by morbid signs”.
Disease per se ,is nothing more than an alteration in the state of health of a healthy individual caused by the dynamic action of inimical forces upon the life principle of the living organism making itself known only by perceptible signs and symptoms, the totality of this represents for all practical purposes, constitute the disease.
Disease is the abnormally altered state of life characterized by disagreeable sensations and functions due to the dynamic derangement of the vital force by the
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morbific dynamic influence inimical to life; these are manifested through signs and symptoms, the totality of which constitute disease.
In §6(Organon of medicine 5th edition), “All these perceptible signs represent the disease in its whole extent, that is, together they form the true and only conceivable portrait of the disease.”
In the footnote to §31(Organon of medicine 5th edition), Hahnemann writes “disease is not mechanical or chemical alterations of the material substance of the body and not dependent on a material morbific substance, but that they are merely spiritual dynamic derangements of life.” Disease is a purely dynamical disturbance of the vital power and functions, which may or may not ultimate in gross tissue changes. Homoeopathy perceives that there is something prior to these ultimate pathological changes. Tissue changes are of the body and are the results of the disease, they are not the disease.
In§70(Organon of Medicine 5th edition), “The every thing of a really morbid character and which ought to be cured that the physician can discover in diseases consists solely of the sufferings of the patient , and the sensible alterations in his health , in a word , solely the totality of symptoms , by means of which the disease demands the medicine requisite for its relief , whilst on the other hand , every internal cause attributed to it , every occult quality or imaginary material morbific principle , is nothing but an idle dream.”
The very foundation of Homoeopathic practice considers man not only as an individual, but as a complete unit in himself, of which all parts comprise a well balanced whole. Homoeopathy, therefore does not consider any one part as being ill, but considers the manifestation of illness in one part in its relation to the whole man.
According to J.T.Kent, “It is a man that is sick and to be restored to health, not his body, not the tissues. The real sick man is prior to the sick body and we must conclude that the sick man be somewhere in that portion which is not left behind. That which is carried away is primary and that which is left behind is ultimate. It is nonsense to say prior to localization of disease, the patient is not sick. The organs are not the man; the man is prior to the organs.”
AETIOLOGICAL CONCEPT OF DISEASE IN HOMOEOPATHY To begin with Dr. Hahnemann did not approach the subject of medicine from the angle of causation, but he tackled the problem of disease by the pure observation of the phenomena. The technique adopted by Dr. Hahnemann is “an intuitive disposition of thinking with phenomenology as the method of research, and analogizing as the way of thinking.” As far the greatest numbers of diseases are of dynamic (spiritual) origin and dynamic nature, their cause is not perceptible to the senses. Homoeopathy considers the morbid vital processes in living organisms, which are perceptibly represented by symptoms, irrespective of what caused them. Homoeopathy 18
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is concerned only with disease per se, that is, in its primary functional, or dynamic aspect, not in its ultimate and so called pathological results. With these we have nothing to do; these are not in any sense the disease but are the results of disease conditions. Therefore we must distinguish between the primary functional symptoms which represent the morbid process itself, and the secondary symptoms which represent the pathological end products of disease.
Homoeopathy is not concerned with the morbific agents any more than it is with the tangible products or the ultimate of disease. Hahnemann regarded the removal of all obstacles to cure as absolutely essential before he attempted to proceed to the selection and administration of the remedy which was homoeopathic to the symptoms of the individual case, by which alone the cure is to be accomplished.
In §5, (Organon Of Medicine 5th Edition) he narrates the aetiology of diseases- “Useful to the physician in assisting him to cure are the particulars of the most probable exciting cause of the acute disease, as also the most significant points in the whole history of the chronic disease, to enable him to discover its fundamental cause, which is generally due to a chronic miasm.”
In footnote to §6, (Organon Of Medicine 5th Edition), “The physician whose researches are directed towards the hidden relations in the interior of the organism, may daily err; but the homoeopathist who grasps with requisite carefulness the whole group of symptoms, possesses a sure guide; and if he succeed in removing the whole group of symptoms he has likewise most assuredly destroyed the internal, hidden cause of the disease"
In§7, “Now, as in a disease, from which no manifest exciting or maintaining cause (causa occasionalis) has to be removed, we can perceive nothing but the morbid symptoms, it must (regard being had to the possibility of a miasm, and attention paid to the accessory circumstances, §5 Organon Of Medicine 5th Edition) be the symptoms alone by which the disease demands and points to the remedy suited to relieve it. The totality of these its symptoms, of this outwardly reflected picture of the internal essence of the disease that is the affection of the vital force must be the principal, in each individual case of disease, must be the sole indication, the sole guide to direct us in the choice of a remedy (§18 ,Organon Of Medicine 5th Edition).”
In footnote to §7, (Organon of Medicine 5th Edition), “It is not necessary to say that every intelligent physician would first remove this where it exists; the indisposition thereupon generally ceases spontaneously. He will remove from the room strong-smelling flowers, which have a tendency to cause syncope and hysterical sufferings; extract from the cornea the foreign body that excites inflammation of the eye; loosen the over-tight bandage on a wounded limb that threatens to cause mortification, and apply a more suitable one, lay bare and put a ligature on the wounded artery that produces fainting; endeavour to promote the expulsion by vomiting of belladonna berries,…...etc., that may have been swallowed; extract foreign substances that may have got into the orifices of the body (the nose, gullet, ears, urethra, rectum, vagina); crush the vesical calculus; open the imperforate anus of the new-born infant, ..etc.” 19
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In §73, (Organon Of Medicine 5th Edition), “As regards acute diseases, they are either of such a kind as attack human beings individually, the exciting cause being injurious influences to which they were particularly exposed. Excesses in food, or an insufficient supply of it, severe physical impressions, chills, overheating, dissipation, strains, .etc., or physical irritations, mental emotions, and the like, are exciting causes of such acute febrile affections; in reality, however, they are generally only a transient explosion of latent psora, which spontaneously returns to its dormant state if the acute diseases were not of too violent a character and were soon quelled. In cases of sporadic diseases and epidemic diseases, aetiology can be of similar in origin. The calamities of war, inundations and famine are not infrequently their exciting causes and produces - sometimes they are peculiar acute miasms which recur in the same manner.”
In §74 (Organon of Medicine 5th Edition), “Among chronic diseases we must still, alas! reckon those so commonly met with, artificially produced in allopathic treatment by the prolonged use of violent heroic medicines in large and increasing doses, by the abuse of calomel, corrosive sublimate, mercurial ointment, nitrate of silver, iodine and its ointments, opium, valerian, cinchona bark and quinine, foxglove, prussic acid, sulphur and sulphuric acid, perennial purgatives, venesections, leeches, issues, setons, ..etc., whereby the vital force is sometimes weakened to an unmerciful extent.”
In §75, (Organon Of Medicine 5th Edition), “These inroads on human health effected by the allopathic non-healing art (more particularly in recent times) are of all chronic diseases the most deplorable, the most incurable; and I regret to add that it is apparently impossible to discover or to hit upon any remedies for their cure when they have reached any considerable height.”
In §77, (Organon Of Medicine 5th Edition), “Those diseases are inappropriately named chronic, which persons incur who expose themselves continually to avoidable noxious influences, due to habit, prolonged abstinence, residing in unhealthy localities, lack of exercise or constant state of worry…..etc These states of ill-health, which persons bring upon themselves, disappear spontaneously, provided no chronic miasm lurks in the body, under an improved mode of living, and they cannot be called chronic diseases.”
In §78, (Organon Of Medicine 5th Edition), “The true natural chronic diseases are those that arise from a chronic miasm, which when left to themselves, and unchecked by the employment of those remedies that are specific for them, always go on increasing and growing worse, notwithstanding the best mental and corporeal regimen, and torment the patient to the end of his life with ever aggravated sufferings. These are the most numerous and greatest scourges of the human race; for the most robust constitution, the best regulated mode of living and the most vigorous energy of the vital force are insufficient for their eradication.”
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These fundamental causes are nothing but miasms which even predispose the person to the attack of acute diseases. They are of three in number –Psora, Sycosis and Syphilis. In these investigations, the ascertainable physical constitution of the patient mental and intellectual characters, his occupation, mode of living and habits, his social and domestic relations, his age, sexual function, ..etc., are to be taken into consideration.
As Stuart Close has well said, the real field of Homoeopathy is “to those agents who affect the organism as to health in ways not governed by chemistry, mechanics or hygiene, but those capable of producing ailments similar to those found in the sick.”
If the physician succeeds in removing the whole group of symptoms and the entire collection of the perceptible phenomena, he has like wise most assuredly destroyed the internal, hidden cause of the disease.
Homoeopathy might well be defined as the science of vital dynamics. Its field is the field of disordered vital phenomena and functional changes in the individual patient, irrespective of the name of the disease or of its cause. Its object is the restoration of order and harmony in vital functioning in the individual patient.
Hahnemann thus distinguishes between disease itself and its causes , manifestations and products , and then shows at once that the sphere of Homoeopathy is limited to functional changes from which the phenomena of disease arise . Thus Homoeopathy operates only in the dynamic sphere. Directly Homoeopathy has nothing common with the physical cause or product of disease, but secondarily it is related.
In footnote to §12, (Organon Of Medicine 5th Edition), “How the vital force causes the organism to display morbid phenomena, that is, how it produces disease, it would be of no practical utility to the physician to know, and therefore it will forever remain concealed from him; only what it is necessary for him to know of the disease and what is fully sufficient for enabling him to cure it, has the Lord of life revealed to his senses.”
PATHOLOGY AND HOMOEOPATHY Homoeopathy differs with regular medicine in its interpretation and application of several fundamental principles of science. It is these differences of interpretation and the practice growing out of them which give Homoeopathy its individuality and continue its existence as a distinct school of medicine.
Modern science in general and medical science in particular, regards the facts of the universe from a materialistic standpoint. It endeavors to reduce all things to the terms of matter and motion
Homoeopathic medical science views the facts of the universe in general, and medical facts in particular, from a vitalistic-substantialistic standpoint; that is, from the standpoint of the substantial philosophy, which regards all things and forces, including life and 21
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mind, as substantial entities, having a real, objective existence. In Homoeopathic philosophy life and mind are the fundamental verities of the universe.
Human pathology is the science which treats diseased or abnormal conditions of living human beings. It is customary to divide the subject into general and special pathology. Special Pathology is divided into medical pathology, dealing with internal morbid conditions, and surgical pathology, which deals with external conditions.
General Pathology bears the same relation to special pathology that philosophy bears to the special sciences. It is the synthesis of the analyses made by special pathology. It deals with principles, theories, explanations and classifications of facts. Homoeopathic General Pathology is concerned with Chronic Diseases. . In formulating his theory of chronic miasms, Hahnemann did for pathology what he had already done for therapeutics. He made a classification of phenomena of disease which led to the broadest generalization in pathology and aetiology that has ever been made and greatly simplified and elucidated the whole subject.
From the dynamic concept of disease, the derangement of vital force is prior to the formation of pathological tissue changes which forms the basis of Hahnemannian pathology. According to him the true cause of all pathological changes is the miasm and hence we base our remedy selection upon these individual miasmatic symptoms.
Hahnemann was the first to perceive and teach the parasitical nature of infectious or contagious diseases, including syphilis, gonorrhea, leprosy, tuberculosis, cholera, typhus and typhoid fevers; and the chronic diseases in general, other than occupational diseases and those produced by drugs and unhygienic living, the so-called drug diseases.
He used the terminology of his day, which he qualified to suit his purpose and thus made it clear that by the word "miasma," amplified by the descriptive terms "Infectious, contagious, excessively minute, invisible living creatures" as applied to cholera, he meant precisely what we mean today when we use the terms of bacteriology to express the same idea.
Among the three miasmatic diseases, psora is the most ancient, most universal, most destructive, hydraheaded and difficult of all the c/c diseases. For syphilis, he says, “Hitherto syphilis alone has been to some extent known as such a chronic miasmatic disease, which when uncured ceases only with the termination of life. Sycosis (the condylomatous disease), equally ineradicable by the vital force without proper medicinal treatment, was not recognized as a chronic miasmatic disease of a peculiar character, which it nevertheless undoubtedly is, and physicians imagined they had cured it when they had destroyed the growths upon the skin, but the persisting dyscrasia occasioned by it escaped their observation” (§79 Organon of Medicine 5th edition.)
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Psora has thus become the most infectious and most general of all the chronic miasms," says Hahnemann. The disease, by metastasis from the skin, caused by external palliative treatment, attacks internal organs and causes a multitude of chronic diseases the cause of which is generally unrecognized.
Hahnemann's teaching is thus elucidated and confirmed by pathology. The infectious, parasitic, primary and typical micro-organism of Psora, driven from the skin by local treatment, finds a ready route to deeper tissues, structures and organs through the capillaries, the lymphatic and glandular systems and the nervous system. Here it develops its secondary specific form and character according to its location and the predisposition and environment of the individual, giving rise to a vast number of secondary symptoms.
Individualization is the cardinal principle of a true pathology as well as of a true therapeutics. A true therapeutics, therefore, stands as the connecting link between pathology and pharmacology.
Bacteriology can never serve as a basis for a reliable and efficient therapeutics for the individual. Since the micro-organism is only one of the many causes of disease, the curative remedy for the concrete, resulting disease in the individual must correspond to the combined effects of the various causes. The combined effects are manifested by groups of phenomena or symptoms which vary, more or less, in the various individuals, according to their conditions and circumstances. As the individual cases of every disease vary in their causes and conditions, and consequently in their symptoms or effects, there can be no specific, general remedy for a disease.
According to J.H.Allen, the Hahnemannian school makes use of the minute symptomatology for the basis of therapeutics, pathology and all else being subservient to it. Homoeopathic prescription can be done even before localization of disease occurs. It is true that Hahnemann never rejected pathology, but put it where it belonged, as part of the whole in the pyramid of symptomatology.
Modern bacteriological science, by long independent research, slowly arrived at the goal Hahnemann reached more than half a century before in regard to the nature and causes of certain forms of disease. It has accomplished much in the way of prophylaxis, sanitation and hygiene through the use of that knowledge; but the profession at large has failed to follow his logical and practical deductions in regard to the cure of these diseases, or to discover a means of cure for itself. In this respect modern medicine is no further advanced that it was in Hahnemann's day. It is obliged to confess and does confess, when driven to the wall, that it has no reliable cure for any disease.
As per Hahnemannian classification, Haemorrhoids comes under dynamic chronic diseases. So, knowing a patient with Haemorrhoids from Homeopathic point of view is concerned with the knowledge of chronic diseases and chronic miasms.
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But in modern medicine, Haemorrhoids are considered as surgical disease. But we must differentiate between the causes of disease and the ultimate of disease: they stand at opposite ends of scale. While these ultimate are not primarily within the range of similia and therefore not the objective of Homoeopathic treatment, the morbid process from which they arise or to which they lead is under the control of Homoeopathic medication. This medication may control and retard the development of pathological conditions. Thus tumors may be retarded or completely arrested and absorption increased, and finally the disappearance of the growth; secretions or excretions increased or decreased; ulcers heal; but all this is secondary to the real cure which takes place solely in the dynamic sphere, restoring the patient to health and harmonious functioning of his whole being by the dynamic influence of the symptomatically similar remedy.
RELEVANCE OF CLINICAL FEATURES IN HOMOEOPATHY Dr. Samuel Hahnemann explains , “Symptoms are the deviations from the former healthy state of the now diseased individual, which are felt by the patient himself, remarked by those around him and observed by the physician” (§6, Organon Of Medicine 5th Edition).
He also says that the unprejudiced observer takes note of nothing in every individual disease, except the changes in the health of the body and of the mind (morbid phenomena, accidents, symptoms) which can be perceived externally by means of the senses. All these perceptible signs represent the disease in its whole extent, that is, together they form the true and only conceivable portrait of the disease. (§6, Organon of Medicine 5th Edition).
In §7, Organon of Medicine 5th Edition , Hahnemann expounds that the totality of symptoms is outwardly reflected picture of the internal essence of the disease, that is, of the affection of the vital force, must be the principal, or the sole means, whereby the disease can make known what remedy it requires - the only thing that can determine the choice of the most appropriate remedy - and thus, in a word, the totality of the symptoms must be the principal, indeed the only thing the physician has to take note of in every case of disease and to remove by means of his art, in order that it shall be cured and transformed into health.
Hahnemann explains that there is, in the interior of man, nothing morbid that is curable and no invisible morbid alteration that is curable which does no make itself known to the accurately observing physicians by means of morbid signs and symptoms - an arrangement in perfect conformity with the infinite goodness of the all-wise Preserver of human life (In §14, Organon of Medicine 5th Edition)
The affection of the morbidly deranged, spirit-like dynamis (vital force) that animates our body in the invisible interior, and the totality of the outwardly cognizable symptoms produced by it in the organism and representing the existing malady, constitute a whole; they are one and the same (.In §15). So after removal of all the symptoms of the disease and of the entire collection of the perceptible phenomena, there should or could remain anything else besides health. 24
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“So it is clear that the totality of the symptoms is the true and only basis for every Homoeopathic prescription”.
For evaluation of symptoms, he says “In the search for a Homoeopathic specific remedy, the more striking, singular, uncommon and peculiar (characteristic) signs and symptoms of the case of disease are chiefly and most solely to be kept in view. The more general and undefined symptoms: loss of appetite, headache, debility, restless sleep, discomfort, and so forth, demand but little attention (§153, Organon of Medicine 5th Edition).
Dr. J T Kent classifies symptoms as General symptoms, Common symptoms and Particular symptoms. Also, he grades each of them into three level as Highest/First, Second and Third. General symptoms are more important than the common symptoms. They help us to diagnose the patient while common symptoms differentiate the more peculiar individualizing symptoms from the disease symptoms.
According to Stuart close, “The Totality of the Symptoms means all the symptoms of the case which are capable of being logically combined into a harmonious and consistent whole, having form, coherency and individuality.”
Technically, the totality is more (and may be less) than the mere numerical totality of the symptoms. The totality must express an idea upon these is based the diagnosis. The classification of symptoms thus made represents the diagnostic idea. Just so the "totality of the symptoms," considered as the basis of a Homœopathic prescription, represents the therapeutic idea. These two groups may be and often are different. The elements which go to make up the therapeutic totality must be as definitely and logically related and consistent as are the elements which go to make up the diagnostic totality
“The Totality is more than the mere aggregate of its constituent symptoms. It is the numerical aggregate plus the idea or plan which unites them in a special manner to give them its characteristic form.”
Thus we determine what is characteristic in the patient and in the remedy; the characteristic symptoms are always the generals of the patient. What is true of one symptom may often be true of the whole patient. Therefore while we strive to form the picture of the totality, we must instinctively evaluate and find ourselves assembling symptom as applying to the whole man or to his individual parts as the case may be.
The fundamental principle of Homoeopathy is law of similars- similia similibus curentur, i.e. diseases are treated by symptom similarity of medicines which are capable of producing similar artificial diseases in healthy individual with the natural diseases.
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SIGNIFICANCE OF INVESTIGATIONS AND DIAGNOSIS OF THE DISEASE “Physical diagnosis is very important in its own place. By means of physical diagnosis the physician may find out the changes in organs, how far the disease has progressed and determine if the patient is incurable.” In Homoeopathy a complete diagnosis is a dual diagnosis i.e. a Homoeopath always makes a differentiation between disease symptoms and patients symptoms from his totality of symptoms after a careful evaluation and analysis .Thus a Homoeopathic diagnosis includes-
1. Disease diagnosis- here also Homoeopath makes double process in order to individualize the disease as individualization is the prime essence of Homoeopathy. · Ds determination –from the knowledge of clinical science · Ds individualization- what particular features of the given disease shows in our individual patient
2. Diagnosis of the person- what kind of a man is our patient who has developed the given disease i.e. his constitutional individuality. This individualization of the person is the cardinal part of our diagnosis.
Constitutional individuality – means three forms in general. · Actual constitutional diagnosis-psychophysical make up · Developmental constitutional diagnosis-his development including hereditary investigation · Environmental constitutional diagnosis-his environment &his reciprocity with it through action and reaction
One of the popular misconceptions about Homoeopathy is that it has little to do with diagnosis of disease and that a Homoeopathic physician does not require the various auxiliary facilities like pathological, biochemical, radiological or other laboratory investigations for the practice of this speciality. But this is not wholly true. What we actually oppose is prescription based on common pathological conditions. It is true that Hahnemann never rejected pathology, but put it where it belonged, as part of the whole in the pyramid of symptomatology.
Although the selection of Homoeopathic remedy does not depend absolutely on the disease diagnosis, but it is important to a Homoeopath in relation to the following aspects.
· To forecast the prognosis · For general management. Diet: Restriction of substances that interfere with medication and also disease progress. Mode of life: For suggestions regarding the hygienic conditions, exercise, occupation etc that has a great influence in the management of diseases
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Auxiliary Management: Apart from medicinal management, in conditions which need auxiliary management is essential in order to save the life of the patient. Such necessity can only be assessed by the diagnosis of the disease.
· For therapeutic purpose. To know the curability of the case: Dr. Kent says, "By means of physical diagnosis the physician may find out the changes in organs, and determine if the patient is incurable. Without diagnosis we may go on applying the medicine in the false hope of curing him."
To select the line of treatment: It enables the physician to discriminate cases that require medicinal or surgical aid. It also distinguishes between that which is curable and incurable, so that we can choose curative or palliative treatment respectively.
To identify the nature of disease: Artificial and natural diseases produce similar symptoms. For e.g.: Comatose condition may be attributed to various causes such as diabetes, opium poisoning, heat stroke etc. Management varies in each case, which can be determined by diagnosis.
To select the homoeopathic remedy: By differentiating between common and uncommon symptoms and also by assessing the stage of disease.
To select the most suitable potency of the medicine: For eg.Advanced pathological changes call for a low potency, as higher potencies provoke serious aggravation and endanger patient's life.
· To follow up the case For ascertaining the effects of treatment: whether the patient is improving not only clinically, but also pathologically by comparing the investigation reports at different periods. For evaluating new symptoms: Diagnosis enables us to decide whether the newly developed symptoms are due to the natural progress of the disease or due to the action of the remedy and thus helps to differentiate between homoeopathic aggravation and disease aggravation.
· For isolation and notification of the contagious disease · To convince the patient and the relatives. · To issue certificates for official purposes such as medical certificates, death certificates etc. · For medico legal purposes · For record keeping, statistical analysis, research works, seminars etc, which go in the way of advancement of the system
SIGNIFICANCE OF DIAGNOSIS OF THE PATIENT The selection of Homoeopathic remedies depends absolutely on the diagnosis of the patient than of the disease. As Individualization is the only basis of our prescription, we have to make not only the disease diagnosis but the patient diagnosis also. Diagnosis of the person means what kind of a man is our patient who has developed the given 27
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disease i.e. his constitutional individuality. This is the cardinal part of our selection of remedy by which we can cure the patient permanently. In order to get this constitutional individuality, we have to take into consideration the actual constitutional -psychophysical make up, the developmental constitution (his development including hereditary investigation) and the environmental constitution (his environment &his reciprocity with it through action and reaction).
Dr. Hahnemann narrates in his memorable article Spirit of Homoeopathic medical doctrine, “Human life is in no respect regulated by purely physical laws, which only obtain among inorganic substances. The material substance of which the human organism is composed no longer follows, in this vital combination, the laws to which material substances in the inanimate condition are subject. They are regulated by laws peculiar to vitality alone.”
It is the characteristic of Homoeopathy, that all its practical processes are governed by the principle of individualization. Homoeopathy recognizes the individuality of each patient or case. Each individual person will show some characteristic variation peculiar to his individuality. When these symptoms peculiar to the individual patient are known, the homoeopathic remedy can be selected.
Thus in §3, Organon of Medicine 5th Edition, he stresses the point that the physician clearly perceives what is to be cured in diseases, that is to say, in every individual case of disease. Dr. Hahnemann advocates a detailed case taking in each case for ascertaining the individual peculiarity of the patient in aphorisms from 82-104
Homoeopathy recognizes the individuality of each drug and substance in nature. In §118, Organon of Medicine 5th Edition, “Every medicine exhibits peculiar actions on the human frame, which are not produced in exactly the same manner by any other medicinal substance of a different kind.” and “so certainly do they all differ and diverge among themselves in their pathogenetic - consequently also in their therapeutic - effects. Each of these substances produces alterations in the health of human beings in a peculiar, different, yet determinate manner, so as to preclude the possibility of confounding one with another.”(In §119, Organon of Medicine 5th Edition)
Therefore medicines, on which depend man's life and death, disease and health, must be thoroughly and most carefully distinguished from one another, and for this purpose tested by careful, pure experiments on the healthy body for the purpose of ascertaining their powers and real effects, in order to obtain an accurate knowledge of them, and to enable us to avoid any mistake in their employment in diseases, for it is only by correct selection of them that the greatest of all earthly blessings, the health of the body and of the mind, can be rapidly and permanently restored.( In §120, Organon of Medicine 5th Edition)
The Wholistic concept is absolutely necessary to understand the living phenomena of every being. Individual is not a mere aggregate of parts but he is a harmonious
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whole. Not only man but the disease and the drug were also tried to grasp as a whole by Hahnemann. This is an entirely new departure in the line of medical thought.
CONSTITUTION AND CONSTITUTIONAL MEDICINE “No knowledge is perfect unless it includes an understanding of the origin- that is, the beginning; and as all man’s diseases originate in his constitution, it is necessary that his constitution should be known if we wish to know his disease” – Paracelsus
Definition of the word ‘constitution’ The word constitution comes from the Latin word “constituere” or “constitute” which means to set up, to establish, to form or make up, to appoint, to give being to.
Chambers Dictionary defines constitutions as, the natural condition of the body or mind; disposition. Constitutional means; inherent in the natural frame or inherent nature. According to S.K.Banerjee “constitution is that aggregate of hereditary characters, influenced more or less by environment, which determines the individual’s reaction, successful or unsuccessful, to the stress of environment”. . Constitution is defined as the structure, composition, physical make up or nature of something, comprising inherited qualities modified by the environment.
Temperament means a peculiar or distinguishing mental or physical character determined by relative proportion of humors. It means characteristic or habitual inclination or mode of emotional response.
The Emergence of Constitutional Types In observing similarities among individuals with respect to traits, behaviors, and patterns of disease, the idea of constitutional types began to emerge.
The philosopher-scientist Theophrastus (B.C. c372-c287) noticed that black bile appeared to dominate in men of genius, and this dominance did not indicate inherent pathology. Here was the first delineation of a psychobiological constitutional type.
The Arabs developed typologic characteristics for all four humors. "Combined with astrological elements", says Sigerist, "the theory was developed and extended still further in the West, in the Middle Ages and the Renaissance."
These ideas provided foundation for the work of Galen (Claudius Galenus, A.D. c130-c200), a Greek physician and writer, who practiced in Rome. In a revolutionary undertaking, Galen dissected the Barbury ape in an effort to discover the loci and actions of humors in organs of the body.
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The concept of temperaments in Western medicine finds origin and early elaboration in ancient Greece; subsequently, it was developed and expanded by the Arabs, followed by Galen and the Romans.
CONCEPT OF CONSTITUTION IN AYURVEDA
Constitution is called as ‘Prakriti’ in Ayurveda
Mental constitution - Vedic philosophy classifies human temperaments into three basic qualities, SATVA, RAJAS and TAMAS. Relative predominance of satva, rajas, or tamas is responsible for individual psychological constitution.
Satvic Mental Constitutions-The people in whom satvic qualities predominate are religious, loving, compassionate and pure minded.
Rajas Mental Constitutions-The people in whom rajas qualities predominate are egoistic, ambitious, aggressive, proud, competitive, and have a tendency to control others. Their activities are self- centered.
Tamas Mental Constitution-The people in whom tamas qualities predominate are less intelligent. They tend towards depression, laziness, and excess sleep, even during the day. They are greedy, possessive, attached, irritable, and do not care for others.
Body constitution - Three body constitutions are recognized -Vata, Pitta and Kapha
Vata qualities- Vata is dry, light, cold, mobile, active, clear, astringent, and it is dispersing. Vata predominant people tend to get neurological, muscular and rheumatic problems.
Pitta qualities- It has hot, sharp, light, liquid, sour, oily, and spreading qualities. Because of the hot quality, the Pitta person has a strong appetite and warm skin. Pitta people tend to get inflammatory disease.
Kapha qualities- Kapha will have heavy, slow, cool, oily, liquid, dense, thick, static and cloudy qualities. They love eating, sitting and doing nothing.
According to the Ayurvedic concept disease depends on these tridhoshas. The selection of remedy also depends on this principle. Based on the aetiology of tri-dhoshas concept, their mode of treatment is to rectify this through the diet and drugs. Constitutional peculiarities of a person are also attributed to the preponderance of or otherwise of the different dhoshas in him even at the time of conception. Some may be with a harmony and equilibrium of
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them but some with vatha predominance, some with pitha predominance and some with kabha predominance.
ANCIENT GREEK CONCEPT OF CONSTITUTION Humorism or Humoralism was a theory of the make up and workings of the human body adopted by ancient Greek and Roman physicians and philosophers. From Hippocrates onward, the Humoralism theory was the most commonly held view of the human body until the nineteenth century and the understanding of the circulation of blood.
Essentially, it holds that the human body is filled with four basic substances, called humors, which are held in balance when a person is healthy. All diseases and disabilities result from an excess or deficit in one of these four humors. These four humors (corresponding to the four elements of earth, fire , water , and air ) were black bile , yellow bile ,phlegm , and blood respectively.
Greeks and Romans, and the Western civilizations that adopted Classical philosophy, believed that each of these humors would wax and wane in the body, depending on diet and activity. When a person had a surplus of one fluid, then that person’s personality, and eventually health, would be affected.
Hippocrates of Kos (460 B C- 370 BC) was an ancient Greek physician. Hippocrates is commonly regarded as one of the most outstanding figures in medicine of all time for his lasting contributions to this field and is often referred to as ‘The Father of Medicine’. He believed that sickness in a human was caused by an imbalance of the four humors. In the latest of the Hippocratic writings (The Nature of Man), atrabilious black bile is distinguished from the bilious humor, yellow bile, and named as one of the four cardinal humors. Equilibrium among these humors (blood, yellow bile, black bile, phlegm) was thought to constitute health.
Aristotle (384 BC- 322 BC) – He was the first who made physiognomy a branch of natural history, of medicine and philosophy. He said it is good to have a method in order to group together all that belong to each type and he described the particular signs of the individual, the disease and humors. Claudius Galen (131- 201) was physician to five Roman emperors. He was a teacher, philosopher, pharmacist and leading scientist of his day .Galen put forward the theory that illness was caused by an imbalance of the four humors –blood, phlegm, black bile and yellow bile. He recommended specific diets to help in the ‘cleansing of the putrefied juices’ and often purging and bloodletting would be used. This theory was accepted until challenged by Paracelsus who believed that illness was the result of the body being attacked by outside agents.
Galen first described human type as sanguine, bilious, phlegmatic and nervous.
SANGUINE- This type has white skin with colored tint; short stature with a short neck having tendency to plethora, congestion, obesity and all kinds of haemorrhages. 31
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BILIOUS- This type has thin and firm hand. The palm is hard and dry, muscular, stuffed and hot.
PHLEGMATIC- This type is characterized by blonde hair, fine and pale skin.
NERVOUS- He is anxious having sudden gestures, with fantastic imaginations, convulsions, ecstasies and all sorts of lung troubles with doubling of personality.
His clinical concepts of causation were empiric, including ideas of initial, evident, external, preceding, active, conjunctive, adjuvant and maintaining causation; this had great appeal for physicians and scientists alike. But his deductive, rather than inductive, approach to constitutional types and temperament made it necessary for him to seek examples of the constructs he generated, and this proved problematic. His theories and system of therapeutics were to influence the study and practice of Western medicine until the renaissance, some 1400 years later.
The Contemporary Schemata
The four cardinal elements (Air, Fire, Earth, and Water) were imagined to comprise the world; all things were composed of these elements, in differing proportions. Elementary forces or qualities were seen to act upon all things. These qualities were innumerable, but four came to be regarded as especially significant: heat, cold, dry, and moist.
The protomodel of four elements and four qualities proved useful in the understanding and classification of natural observations, but was not sufficiently specific to organic life. Attempts to comprehend the basis of health and disease required a new formulation, a new schema.
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According to Henry E. Sigerist, M.D., black bile "was held responsible for a great variety of diseases, ranging from headache, vertigo, paralysis, spasms, epilepsy, and other mental disturbances, to quartan fever and diseases of the kidneys, liver, and spleen". Sigerist reports that this treatise, commonly attributed to Polybus, is the starting point for humoral theory.
In the 19th and Early 20th Centuries - The idea of the four humors has deeply affected our concept of personality. Sanguine, choleric, melancholic, and phlegmatic remain meaningful adjectives in our vocabulary. Popular books on humoral typology appear from time to time.
The perception that people are similar, that they exhibit characteristics or attributes which may be classified by type was a key premise in the psychologies of the past century. The number four figured prominently in many of the theories developed during this period. William Strauss and Neil Howe tell us that the four temperaments "regained some of their former esteem", in the twentieth century.
The turnabout came in the years around World War I, when a new generation of European psychologists revolted against positivism and made the fourfold thinking popular again. E. Adickes wrote of four worldviews (traditional, agnostic, dogmatic, innovative); Eduard Spranger of life types (theoretical, aesthetic, religious, economic); Ernst Kretschmer of abnormal temperaments (anesthetic, hyperesthetic, melancholic, hypomanic); and in the twentieth century's best know quaternity, Swiss psychologist Carl Jung wrote of attitude types based on psychological functions (thinking, intuition, feeling, sensation).
The model below is adapted from the work of Melvyn Kinder, in Mastering Your Moods posits two continua, one indicating action tendency in terms of extroversion and introversion, and the other, state of arousal. He identifies four temperaments (sensor, focuser, seeker, discharger), placing each in a quadrant indicating its action tendency and threshold of arousal. For instance, the sensor is extraverted and easily aroused. Kinder provides descriptions for each temperament, and one clearly can see in these the key features of ancient humoral prototypes. Kinder's four temperaments are readily correlated with those of humoral theory.
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Myers-Briggs core types also correspond to the Kinder which in turn correlated with the humoral types.
Seeker ==== Sanguineus ==== sensation perceiving Discharger ==== Cholericus ==== intuitive thinking Focuser ==== Melancholicus ==== intuitive feeling Sensor ==== Phlegmaticus ==== sensation judging
Hans Eysenck studied two continua – extrovert & introvert and stable & unstable plotting his results in four quadrants which, it is suggested, might represent the four temperaments – Melancholic, Phlegmatic, Choleric, and Sanguine.
Dragan M. Svrakic et al. present a seven-factor model of temperament and character, developed to facilitate differential diagnosis in personality disorders. They evaluate the efficacy of self-reports to read a comprehensive personality of seven dimensions, including novelty seeking, harm avoidance, reward dependence, persistence, self- directedness, cooperativeness, and self-transcendence
C. Robert Cloninger et al., with Svrakic contributing, describe these seven factors in terms of a psychobiological model of temperament and character. They delineate self-directedness, cooperativeness, and self-transcendence as character traits; novelty seeking, harm avoidance, reward dependence, and persistence were distinguished as temperament traits
In this sketch of contemporary schemata, we have seen that contemporary formulations may be correlated with the temperaments of humoral theory. Although there arose a split between mind and body in the subsequent history of Western thought, there was no separation in ancient theory. Contemporary psychobiological models are exploring this unicity again, in dimensions quite beyond the scope of the ancient schema, even as Freud and Jung anticipated.
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HUMAN TYPES ACCORDING TO SIGAUD
It was Claude Sigaud who studied human types, basing himself on ‘man in function of the ambience’. His study was based on the observation of 20th century human being and he has described these types in a language adapted to our modern conceptions. According to him the human types are Respiratory, Digestive, Muscular, and Cerebral.
· Respiratory - Relatively small trunk. Thorax is well developed. The extremities are muscular. Diamond shaped face with predominance of upper medial part
· Muscular – Considerable development of extremities and muscles. There is no disproportion between the thorax and abdomen. Rectangular or square face.
· Cerebral - Scull capacity is developed. The upper cerebral part of the face is much more developed. The whole face resembles to that of a top.
· Digestive – Slight predominance of lower portion of palm which is fleshy and piriform. Lower of face is well developed.
CONSTITUTION ACCORDING TO VARIOUS AUTHORS
The quest for the constitutional basis which modifies human suffering has been the task of all the great masters of medicine.
Many observers in all schools have noticed certain tendencies to particular disease manifestations in certain types of individuals and among those who have succeeded in reducing the forms to specific types there is a fairly unanimous selection of the number three.
BAZIN reduces all chronic diseases to three forms- scrofula, gout, syphilis, from which he thinks that all other pathological forms originate.
RADEMACHER also found a three fold division. His division was an aetiological or causative one, and varied as the particular cause at work .In some epidemics one type would rule and remedy for that type would be Copper. At another season a some what different type would prevail and for that Iron would be needed; for a third again Cubic Nitre or natrum nitricum would be the remedy. And each of these remedies had allied remedies of its own type.
DR.VON GRAUVOGL’S CLASSIFICATION (1811-1877) - It was through Hahnemann’s insistence on the necessity of observing concomitant circumstances in relation to symptoms that Dr.Grauvogl was led to make his great generalization.
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In Grauvogl’s view it was not the cell but the molecule which was the unit of living processes and on this perception his division of the basic constitutions of man into three is founded.
Of the human body three fourth are made up of water-that is of oxygen and hydrogen. Carbon and nitrogen account for the most of the remainder. The health of the body depends on the constant and regular interchange between the tissues and gases effected by the blood.
On any constant plus or minus of any of these elements in the blood and tissues depend the basic differences in the constitution of the individuals so affected. And in these differences –revealed in their symptoms – are found indications for remedies which override indications which might be drawn from the separate symptoms taken independently. Grauvogl’s vision was of the whole; he did not regard the human organism as made up of independent parts.
Grauvogl’s great achievement consist in his having shown that in prescribing for a patient his constitution often counts for more than the particular complaint in which it manifests itself. He also showed how these different constitutions could be recognized and remedied. Once the constitution is known and cured, all the rest of the symptoms clear up.
The air we breathe is composed of Oxygen, Carbon, Hydrogen, and Nitrogen of which the whole organism is composed and which are even contained free in the blood. Thus changes of the atmospheric constituents affect the whole of the organism. It is in this conception as explaining Hahnemann’s observation of the effect of the various seasons and climatic conditions on patients and drug provers that Grauvogl’s arrangement of the constitution is based.
“The homeopath abstracts from the symptoms the individuality of the patients in connection with the state of the outer world in which they have existed from their birth and out of which the bodily constitution is developed. The bodily constitution is hence the general cause”.
“Such constitutional conditions which make them known by accompanying circumstances, give us, the only right indication”. Thus the mind of Von Grauvogl worked to map out the ‘generals’ and to find the basic remedies for the constitutions out of which arose such a multiplicity of apparently different diseases but really only different manifestations of one and the same disease.
Grauvogl arranged the morbid constitution according to excess or deficiency of certain elements in the tissues and blood. According to him constitution is classified into three.
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· The Hydrogenoid constitution is characterized by an excess of hydrogen and consequently of water in the blood and tissues. · The Oxygenoid constitution is characterized by an excess of oxygen, or at least by an exaggerated influence of oxygen on the organism. · The Carbo-nitrogenous constitution is characterized by an excess of carbon and nitrogen.
The Hydrogenoid constitution corresponds closely with Hahnemann’s sycosis, but it covers a much wider area and is not by any means confined to the acquired or inherited result of gonorrheal infection. The oxygenoid constitution corresponds to Hahnemann’s syphilis. The Carbo- nitrogenoid constitution is Hahnemann’s Psora.
THE HYDROGENOID CONSTITUTION
“There is a constitution of the body which in many cases is the product of gonorrheal contagion. But the cause of that disease which Hahnemann arranged under the head of Sycosis is not the only cause of development of this state of the body which is distinguished by a too great proportion of water, or by hygroscopic blood. I recognize this constitution of the body by the circumstances accompanying any disease”.
“If the patient states that he feels worse in cold or damp weather, and in the rain ,then I know that I have to choose among the remedies which are similar to his disease , such only as contain a greater percentage of a combination of O with C and H , consequently produce more heat and diminish the influence of water.”
The symptoms of a disease in this constitution are aggravated by the things that increase the atoms of water, as fishes, by cold, cooling food and drinks, sour milk, hard eggs, cucumbers, mushrooms but chiefly by living near water and especially standing water.
“Another sign that a disease has occurred in such a bodily constitution I find in the periodicity of its phenomena and chiefly in its irregular and paroxysmal course. Those nervous affections which are exacerbated by electric disturbances appear under this bodily constitution.”
In cases where there is a combination of the Hydrogenoid and carbo- nitrogenoid constitution, the Hydrogenoid must be cured first and then the carbo- nitrogenoid. This corresponds with Hahnemann’s direction regarding sycosis and Psora- where sycosis was to be dealt with first.
Remedies for this constitution - Those substances must be curative of it which prevents the influence of water on the blood such as Glauber’s salt (Natrum sulph). Since in this constitution in which hydrogen frequently seems to have usurped the place of nitrogen the problem is not only to diminish the influence of hydrogen , but where it is possible, to preserve at the same time tissues rich in nitrogen . 37
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He says that alkalis promote the operation of oxygen by means of the respiratory process. If we compare the various localization of pathological processes in this constitution or their specific forms with the homeopathic drug proving-Nitric acid, Natrum carb, Nat accet and Sal ammoniac which can be regarded as remedies for this constitution .
Nutritional remedies like Calc.carb, Mag. carb, Mag.phos, and Silicea serve as remedies for this constitution. He also suggests remedies like Iodine, Bromine, Chlorine, Nitr.acid, Borax, Antimony, Alumen, Thuja, Carb veg, Arnica, Aranea diadema, Puls, Nux vomica in alteration with Ipecac or with Arsen, Conium, Apis, Spigelia and animal food.
THE OXYGENOID CONSTITUTION The Oxygenoid constitution tends to have an excess of oxygen and consequently exaggerate breaking down of hydrocarbons, nitrogenoid and albuminous tissues and bones. We see this in Syphilis and its analogue in medicine- mercury. Thus this constitution corresponds to Hahnemann’s Syphilis. The constitution whether inherited or acquired is of a grave character. A weakened power of resistance against the destructive energy of oxygen may be acquired by attacks of acute epidemic disease and by syphilitic infection. The incubation period required by the disease between the original infection and the out break of symptoms is the period required for the increase of poison up to the degree necessary to make it efficient. These poisons must therefore living organisms which induce the most intense process of reduction , so changing the constitution of the body as to render it unable to resist an immediate influx of oxygen . Grauvogl included under the term oxygenoid much more than is included under Hahnemann’s syphilis.
He believed that poison of syphilis should arise denovo from ferments generated in impure vaginae and that it depended on the constitution of the individual in question which disease followed from one and the same exposure. From the same woman, on the same day and in the same hour, one may get a syphilitic ulcer, one a sycotic ulcer and one escape without infection. It depends on the constitution of the recipient which disease is communicated. The so called chancre dyscrasia is produced from the oxygenoid constitution. Chronic disease which results from these conditions from the begetting of chancre poison will be cured by mercury.
Remedies for oxygenoid constitution - As there is too active influence of oxygen on the body, the remedies are mainly in the carbon and nitrogen series which prevent the oxidation of tissues .Grauvogl puts Kali- iodatum in the first rank as it absorbs all the ozone. Graphitis, Petroleum, kreosot, Benzoic acid, Citric acid, Hydrocyanic acid, Laurocerasus, Antozone water, corresponding indeed to iodosmone water. Nitric acid , Aconite, china, Quinine and Arsenic ( given alone and alteration with Nux ) and also the metals which are capable of suspending the process of decomposition such as Chromium and Kali- bich .Thus it can be seen that remedies for the oxygenoid constitution are largely anti-syphilitic remedies as recognized in Homeopathy. 38
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Dr. Pascal gives a summary of oxygenoid constitution. Oxygenoids are thin and weigh less than carbo- nitrogenoid of equal volume. This provokes the rising up of protenoid materials and cellular frame work Scrofula, rickets, infantile atrophy and various states called anemia result from this.
Oxygenoids feel better in an atmosphere saturated with nitrogen and carbon, in midst of resinous, fatty or empyreumatic vapours. They refuse easily oxydisable animal food and seek for fats and hydrocarbons which oxidize slowly.
They are worse when dryness is changing to humidity, before storm, before and during tempestuous winds and better when it begins to rain or snow or electrical equilibrium is restored .They are worse in foggy weather and when with a temperate air, mists arise from the forest.
Electrical disturbances aggravate and electrical equilibrium relieves oxygenoid. This phenomenon can be traced to a plus or minus of atmospheric ozone. Electric attraction polarizes atmospheric oxygen and transforms it into ozone and antozone. It is after undergoing this modification that it becomes an effective and energetic oxidizer. Electric disturbances then act as hyperoxidents and this account for their aggravations. Other symptoms are – · Excessive elimination of urea and phosphates. · Plethora – great quantity of blood. · Much oxygen fixed on the heamoglobin. · Excessive thinness · Animal heat -strong after meals and feeble in the intervals. · Vigorous appetite which persist astonishingly during illness. · Amelioration by rest and food. · Aggravation by cold, sea – air, low altitudes. · They are nervous individuals characterized by great physical and mental activity.
THE CARBO- NITROGENOID CONSTITUTION This constitution is characterized by insufficient oxygenation and the diseases it produces are called diseases of retarded nutrition. This makes for increased liability to disease and perverted nutrition.
After a period of obesity, thinness follows. Albuminoids are decomposed like hydrocarbons. There is pseudo albuminuria, phosphaturia, acetonemia, rickets, and osteomalacia. General symptoms are great frequency of respiration with shallowness; short breath, frequent pulse, blood charged with melanotic cellules. Constipation or diarrhea, flatulence, urinary troubles, gouty pains in the head , gouty swellings, vertigo , ataxia, dullness of head ,somnolence, yawning, hypochondriasis, irritability and extra ordinary impatience.
Other symptoms are – 39
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· Copious uric acid and oxalates in urine. · Epistaxis and haemorrhoids. · Pruritis · Precocious baldness with perspiration of the head. · Cerebral fatigue. · Unhealthy skin. · Fetid and acrid perspiration · Boils, eczema, urticarea. Causes of aggravation -
· Everything that hinders oxidation. · Everything which increases hydrocarbons and albuminoids. · Everything which diminishes the alkalinity of the humors.
Factors of aggravation - Ø Rest, Non-ionized mists Ø Irritation of cerebro- spinal or sympathetic nervous system Ø Sexual excess, over – feeding, chagrin Ø Respiratory insufficiency, confined air Ø Loss of blood or blood letting which diminishes the number of blood globules and consequently oxidation. Ø Excess of sodium salts, like sea salts, which hinders cellular osmosis and diminishes the quantity of water in the tissues.
Remedies for carbo- nitrogenoid constitution - Grauvogl says that this constitution lacks ozone and is rich in carbon and nitrogen. So it finds its chief remedy in ozone and ozonated water. Remedies which facilitate splitting up of hydrocarbons and albuminoids and the discharging of oxygen are also applicable in this condition. For example: Cupr, Phos. Sulph, Camph, Hepar suph, Aco. Merc, Aur, Argent, Plump, Plat, Rhus, Dulc, Cham, Lyco, Bov, Bell, Nux, Digit, Hyos, Apis, Lob.
ERNST KRETSCHMER (1921): By taking a limited number of physical characteristics Kretschmer classified constitution into asthenic, athletic and pyknic.
Asthenic refers to frail, linear physique. A deficiency in thickness combined with an average unlessened length. Lean narrow built with an unhealthy skin poor in secretion , narrow shoulders, delicate muscles and bones, elongated limbs, narrow flat chest ,sharp rib angle, and thin stomach. Immature old age.
Athletic constitution is characterized by strong development of the skeleton, musculature and skin, a medium sized man with projecting shoulders, superb chest, firm stomach and trunk tapers in its lower edge so that the pelvis and the magnificent leg seem almost graceful compared with
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the size of the upper limb and particularly hypertrophied shoulder. The head seems dolichocephalic.
Pyknic refers to plump physique. The size of the body is medium. Extremities are round. The neck rises gracefully from the two sides of the shoulders.
DR. NEBEL’S THREE CALCIC CONSTITUTIONS It is Dr. Nebel of Lausanne who first described the Calcic constitutions. Starting from the pathogenesis of the three calcareas ,Calcarea carbonica, Calcarea phosphorica and Calcarea fluorica, Dr. Nebel first described the carbo – calcic or carbonic which he also calls normocrinic, phospho-calcic, or phosphoric which he also calls hypercrinic and flouro- calcic or fluoric which he also calls hypocrinic. The three calcareas are the basic remedies of some individuals having a particular morphology, and they help us to find out a series of remedies which will suit the individual during the whole life of the individual.
Later Dr. Vannier described these constitutions in detail. The characteristics of Carbonic constitution are mentally and physically upright persons, having square white regular teeth, slight acute angle between fore- arm and upper- arm, orderly, undemonstrative, responsible and capable. They are rigid and straight. Regularity is a prominent feature which is seen in movements. They are Psoric in nature. Calc Carb, Kali Carb, Mag Carb, Nat Carb, Graph, Carbo veg, Carbo anim are the drugs having this constitution.
Phosphoric constitution has scrofulous or tubercular diathesis. Tall, thin delicate, easily tired persons with long yellow teeth but well fitted. Arm forms perfect straight line when stretched. Dislike hard work, but orderly and fastidious. Imaginative and emotive. Easily becomes enthusiastic and depressed. They are essentially expressive and depend on his momentary impressions. He searches for perfection. He cannot become master of anything. Usually sycotic in nature. Calc phos, Phos acid, Kali phos, Phos, Mag phos are the main drugs.
Fluoric constitution is characterized by unbalanced irregular body formation with; teeth grey, irregular and ill fitted; untidy, cunning and unreliable. He is physically and mentally unstable. Irregularity and disorderliness are the essential characteristics. He requires guidance and orientation. Has fits of fear without reason. Sense of inferiority feeling which leads him to a superiority complex. Capable of heroism, sanctity and wickedness. Predisposed to diseases of nervous system, dislocation of the joints and suicide. Mainly syphilitic in nature .Fluoric acid, Calc flour are the main drugs.
HISTORY OF DOCTRINE OF CONSTITUTION IN HOMOEOPATHY
In his ‘Organon of Healing Art’ (1810) Hahnemann had presented his new method of healing systematically. ‘The Law of Similars’ made the basis of selection of remedy. But later he became doubtful about the full efficiency of such a method of drug selection in chronic diseases because of the recurrence of illnesses in spite of all the careful selection. He recognized that in chronic diseases one had to deal with a separate fragment of a 41
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deep lying original disease. Then he sought for the original evil which is responsible for the diversity of chronic disease manifestations.
He was not satisfied with the recognition of only the endogenous causative conditions but he went farther in the conception of a few exogenous causative damages. According to his view they must be of a ‘chronic miasmatic nature’ .These diseases show such a permanence and continuance that as soon as they have developed increase ever more and more, not lessened even by the intrinsic powers of the most robust nature nor by a healthy mode of living and diet, still less conquered and removed, never depart of themselves but grow and increase until death.
According to Hahnemann there are only three such chronic infections as causes of not all but most chronic diseases namely Syphilis, Sycosis or the fig wart disease and Psora which has the itch eruption lying at its base. In respect to syphilis Hahnemann gave a significance which is approximately that which we attribute to it at present. By Sycosis he understood the general involvement of complicated gonorrhea in which the local symptom is expressed as the fig wart.
Hahnemann emphasized the Psora as of utmost importance. Psora is the oldest, most universal, most pernicious and still usually mistaken chronic miasmatic disease .At least seven eighth of all chronic illness is due to Psora. It is the beginning of all physical sickness. It is the primitive or primary disorder of human race. It is the disordered state of human race. It is considered as the mother of all chronic diseases. It is the most ancient and most destructive of all chronic miasms.
When the internal infection is completed, it comes out on the skin in the form of small vesicular eruptions with a peculiar odour and terrible itching. These are the symptoms of Primary Psora. When the primary manifestations of Psora are suppressed by local applications, the local cutaneous eruptions disappear but the disease is driven inwards and may remain dormant. This state is called the latent state of Psora. Later on it produces various forms of disease conditions like mania, hysteria, cancer, jaundice, haemorrhage etc. This occurs when the person who has the Psora slumbering within has exposed to some exiting or maintaining cause. Thus it becomes Secondary Psora
Sycosis is the venereal fig wart disease, a venereal chronic miasm primarily manifested externally by the condylomatous growths following impure coition. When these are removed by external measures some other secondary ailments worse than the primary one result
Syphilis is a venereal chronic miasm primarily manifested outwardly by the venereal chancre developed following an impure coition. When the primary manifestation is driven out by some local treatment the nature develops far more secondary ailments through the out break of whole chronic syphilis
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These chronic miasms have passed through many generations of people with different congenital corporeal constitutions and exhibit their symptoms in various diversity. The miasms influence the constitutional make up of an individual to a great degree .In fact it is one of the intimate aspects of constitution
Thus the concept of morbid constitution is closely related to the theory of chronic disease in Homoeopathy
In the text book of Organon of Medicine, Hahnemann speaks of Constitution in different aphorisms
In the German text, the word “beschaffenheit” has been translated in to English as the word constitution. In the introduction to Organon of Medicine ,he speaks about the constitution in many places. “The vital force I say produces in accordance with the laws of the constitution of the organism to which it is subject a disease of a different sort intended to expel the disease by which it was attacked”
He again refers to constitution in the discussion of vermicular diseases. A few lumbrici may be found in some children in many there exists ascarides .But the presence of these is always dependent on a general taint of the constitution and the former cured homoeopathically which is most easily effected at this age
Then he speaks about the impossibility of vital force to cure itself and act according to the constitution But the vital force which of itself can only act according to the physical constitution of our organism and is not guided by reason, knowledge and reflection was not given to man to be regarded as the best possible curative agent to restore those lamentable deviations from health to the normal condition
In the aphorism no.5 (Organon of Medicine 5th edn) Hahnemann discusses the fundamental cause which is based on chronic miasm and how to investigate it. In these investigations, the ascertainable physical constitution of the patient (especially when the disease is chronic) , his moral and intellectual character, his occupation, mode of living and habits, his social and domestic relations, his age sexual function , etc…. are to be taken into consideration’. Here he emphasis the importance of constitutional symptoms in the treatment of chronic disease.
In Aphorism no. 52 while criticizing the result of dissimilar allopathic treatment, Dr.Hahnemann says that they ruin the constitution of the patient. ‘….thus at a sacrifice of the patient’s strength, a morbid state quite heterogeneous and dissimilar to the original one, to the ruin of his constitution, by large doses of mixtures of medicines generally of unknown qualities’.
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In Aphorism no. 78, he says that in case of true chronic disease the most robust constitution, the best regulated mode of living and the most vigorous energy of the vital force are insufficient for their eradication.
In Aphorism no .81, the influence of congenital corporeal constitution in the manifestations of Psora is discussed.
In Aphorism no.102, in order to find out the genus epidemicus he says that the totality of the disease cannot be learned from one single patient, but is only to be perfectly deduced (abstracted) and ascertained from the sufferings of several patients of different constitutions.
In Aphorism no. 117, Idiosyncrasy is defined as a peculiar corporeal constitution which, although otherwise healthy, possesses a disposition to be brought into a more or less morbid state by certain things which seem to produce no impression and no change in many other individuals.
In Aphorism no.135, says that drug proving is complete only when medicines are tested on various constitutions.
In the foot note to Aphorism no.246, Hahnemann says that in the repetition of dose many factors are taken into consideration. 1). Nature of the medicinal substance 2).Corporeal constitution and 3). Magnitude of the disease.
DR. KENT’S VIEW REGARDING CONSTITUTION Dr.James Tyler Kent says ‘physical constitution is the external disorder in the man, the vital force’. He also says that there are constitutional states in patients by virtue of which they are always affected in a certain way. We can observe these factors in his Lectures on Homoeopathic Philosophy and Kent’s Lesser Writings. LECTURES ON HOMEOPATHIC PHILOSOPHY:
In lecture16: OVERSENSITIVE PATIENTS. There are constitutional states in patients by virtue of which they are always affected in a certain way, and these states are often left after proving, or are found in those who have been poisoned by drugs. All these patients will have alternating symptoms which will confuse the physician before he knows their constitutional state.
It is an important thing to know the constitutional state of a patient before prescribing .You will always be able to do better for your patients when you know all of their tendencies. Of course, in acute disease symptoms sometimes stand out so sharply that an acute remedy can be administered without reference to any constitutional state. But acute cognates can be established in almost any patient. The acute symptoms fit into and are established and formed by the constitutional state of the patient
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In lecture 21: CHRONIC DISEASE – SYCOSIS The suppression cannot bring on the constitutional symptoms called sycosis .It cannot be followed by fig warts, or constitutional states, such as anemia. But while constitutional symptoms cannot follow the suppression of the acute miasm they will follow suppression of the chronic miasm, and become very serious.
When the suppression occurs, if it is on vigorous constitution, it will localize in the surface in the earlier stage. If it is in weak constitution it will be in deeper tissues. Then the patient thinks that he is cured but the disease goes on into an advanced state.
In lecture 29: IDIOSYNCRASIES: There are persons who are sensitive, not merely to one or a few things, but to all things; oversensitive to the high potencies, oversensitive in taste, oversensitive to light, and a great many other things. This is a constitutional state; the patient is born with it. DR. KENT’S ‘LESSER WRITINGS’:
In SYPHILIS AS A MIASM- Thus syphilis, being a constitutional disease, is made, I may say, ten more constitutional by suppression.
In HOMEOPATHY: ITS FUNDAMENTAL PRINCIPLES OUTLINED- Hahnemann describes three constitutional miasms that may exist in latency, that develop and progress in the vital ‘dynamis’ without changing the tissues, which may spring into destructive activity and attack organs and give shape to countless lesions called disease; that these miasms should be recognized as primary wrongs out of which grow incurable maladies, and all structural changes.
In his lesser writings (page 272) he highlights the importance of individualization of constitution of each patient. ‘The symptoms that represent the morbid constitution or disorder of the individual are the ones that the skillful prescriber always seeks’.
DR. STUART CLOSE’S VIEW REGARDING CONSTITUTION
According to Stuart close ‘constitution is that aggregate of hereditary characters, influenced more or less by environment, which determines the individual’s reaction, successful or unsuccessful, to the stress of environment’. He also says that constitution and temperament modify susceptibility. While giving medicine sensitive persons of nervous, choleric or sanguine temperament can receive higher potencies. Lower potencies are suitable to torpid and phlegmatic individuals.
DR. H.A ROBERT’S VIEW REGARDING CONSTITUTION
In his work The principles and art of cure by Homeopathy, he gives a chapter on temperaments. There are four classical temperaments - Nervous, bilious, sanguineous and phlegmatic. There are many combinations of these temperaments. 45
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These temperaments are to a very large extent physiological. But besides the stature of the patient it includes colouring, functional tendencies of the circulation, elimination, respiration, mental and emotional tendencies in reaction to environment. The matter of temperaments is closely allied with the basic dyscrasias.
It has been said that the temperaments are cast in the very beginning of the new individual and it can not be influenced or changed by the action of our remedies. But a homeopathically indicated remedy, prescribed accurately in children can modify the physiological tendencies as to prevent their unfavorable ultimates.
The Homoeopathic prescription is often biased by the temperament to the extent that certain temperaments bring out certain symptom picture more readily. Various remedies have brought different proving in different temperaments, but the recorded symptoms are useful in ant temperament.
He also says that prescribing on types or temperaments is at best a slack method of using the blessings of homoeopathy.
DR. RICHARD HUGHES’S VIEW REGARDING CONSTITUTION
In his book The Principles and Practice of Homoeopathy in the chapter Administration and selection of similar remedy, he says that the similar remedy should be given singly, rarely and constitutionally. It is chosen from the correspondence of the totality of the symptoms with those of the patient, that it may embrace the whole malady.
DR. DUNHAM’S VIEW REGARDING CONSTITUTION In his book Homoeopathy The Science of Therapeutics, in the chapter “On alternation of remedies”, he says “the constitutional disturbances are even more important indications for treatment than the more obvious and objective symptoms. But how can we analyze the more obvious symptoms, and ascertain those constitutional disturbances in which they have their own origin? In no other way than by a study of the functions of the entire organism. But this brings us at once to that rule on which Hahnemann so strongly insisted, that the entire organism of the patient should be examined in every possible way, and that the ‘the totality of symptoms’ should be made the basis of prescription; may that the general symptoms are often more conclusive as to the proper treatment than the more obvious local symptom”.
In works on Collection of Papers – Cholera, Dunham explains about constitutional prescribing. ‘Hereditary patterns reflect our constitution- the environment in which we live and our life style, including diet. In constitutional prescribing both the physical and psychological symptoms are expressed by the patient and these symptoms are used by the physician to prescribe a remedy’.
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DR. HERING ‘S VIEW REGARDING CONSTITUTION Dr. Constantine Hering created a separate section for constitution and temperament in his Materia Medica called “stages of life and constitution”.
Hering’s provings and clinical confirmations are the source of constitutional characteristics such as : Nux vomica is well adapted to angry, irritable, dark ,thin, dry , bilious, choleric ; Pulsatilla is well adapted to gentle , blond haired , blue eyed phlegmatic temperaments … Such characteristics do not lead to remedies by themselves as they are only part of the over all totality of the symptoms as they represent constitutional general symptoms.
DR. PROCESO SANCHEZ ORTEGA’S VIEW REGARDING CONSTITUTION
Dr. Ortega says “Sickness is manifested in each individual by his own personal characteristics which are seen to yield determinate patterns that compel us to formulate groups with common constitutional basis. In these groups sickness is manifested through similar pathological expressions.”
He is of the opinion that in order to attain the true totality of the symptoms, all the predisposing factors in the patient’s surroundings as well as those deriving from his temperament or constitution, these being the necessary causes of the particular anomalous configuration of this person’s existence. Such knowledge is deduced from our familiarity with human being in general as well as with the given patient’s particular mode of expression.
He also explains that we must focus on the predisposing factors in the given individual and the way he reacts to them. This is accomplished by analyzing his biopathography and recognizing his constitutional pathological response to the numerous stimuli in his surroundings. This is precisely the domain of the miasm- whether deficiency, excess or perversion or their blends.
DR. R.K. MUKHERJI’S VIEW REGARDING CONSTITUTION In the introduction to his book Constitution and Temperament, he gives an account of the term ‘constitution.’ According to him, the homeostatic state of the individual’s interior vitality which is subject to only minor modifications is called his constitution. It is necessary to know the individual from the points of view of his constitution and temperaments when he becomes ill. Constitution is ‘what is’. Temperament is ‘what becomes’. Constitution is the backbone of the individual upon which he builds himself.
Constitution is static. It will not change. Temperament is ‘dynamic’. It is the ensemble of all the possibilities in the physical, psychological, biological and dynamic sphere of the individual. Temperament changes temporarily on the constitutional ground.
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According to Pro.Minkowski, constitution is defined as the ensemble of characters of the individual performed from the very beginning of the biological existence and transmutable as such hereditarily.
DR. K.N. MATHUR’S VIEW REGARDING CONSTITUTION In his foreword to ‘Organon of Medicine’, Dr.Mathur gives division of constitution - The dynamic and adynamic constitution. Patients with good resistance and well developed immunity mechanism are included in dynamic variety. They are curable patients. The adynamic constitution includes patients with poor reaction and immune system. They fail to respond to dynamic medicines.
FACTORS RELATED TO CONSTITUTION · Physical make- up of the body · Temperament · Heat and cold relation · Desire, aversion and intolerance to food · Miasm · Diathesis · Susceptibility and responses · Addiction, habits, etc.
CONSTITUTIONAL MEDICINE: means the medicine which can correct the constitutional defects- inherent and acquired. Every antimiasmatic medicine is a constitutional medicine.
In order to make a constitutional prescription, every physician must know that the remedy that covers the totality of symptoms, covers the existing miasm, which is the fundamental cause of the disease. This has to be individualized in each case and in each remedy.
Individualization is the highest purpose of existence. Instead of an unformed and unconscious mass, one has to become conscious, cohesive, individualized ,that which exist by itself and in itself independently of its surroundings, that which can hear, read, see anything and will not change because of that. It receives from outside only what it wishes to receive. It rejects automatically that does not agree with its purpose, nothing can bear any impression upon it unless it wishes to have the impress. It is then that one begins to be individualized.
The concept of individuality leads to the concept of personality and constitution. Personality is the highest expression of individuality. Personality is a pattern of being marked out by a settled combination of fixed qualities, a determined character. This term is also used to express the continuance of a person’s distinguishing qualities, personal identity in spite of mental and physical changes. It is because of the individual personality that we come across individual constitution which is manifested by inherent tendency to respond automatically along certain qualitatively predetermined, characteristic response –patterns in identical situations. 48
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So constitution implies the aggregate of all sufficiently stable functional and morphological characteristics of an organism, which determines the specificity of its reaction to external agents and are formed on the basis of heredity and acquired properties in interaction with the external environment, primarily the social environment, in the case of man.
In a nutshell the constitution means the inborn traits cum environment, having genetic background. As the gene varies from individuals to individuals, so also is the constitution. It is because of this unique nature of constitution it has been assigned a significant role in Homoeopathy.
ANATOMY OF ANUS AND RECTUM
“No Homeopath ever discouraged the true study of anatomy and physiology. It is important not only to know the superficial but the real, profound character, to enable you to recognize one symptom image from another.” EMBRYOLOGICAL ANATOMY OF RECTUM AND ANAL CANAL The epithelial lining of the various parts of the gastro intestinal tract is of endodermal in origin. In the region of mouth and anal canal, however some of the epithelium is derived from the ectoderm of the stomatodaeum and of the proctodaeum respectively. Due to the establishment of the head and tail folds, part of the cavity of the yolk sac is enclosed with in the embryo to form the primitive gut. It is in direct communication with the rest of the yolk sac. The part of the gut cranial to this communication is the fore gut; the part caudal to it is the hind gut while the intervening part is the mid gut. Cranially the foregut is separated from the stomatodaeum by the buccopharyngeal membrane. Caudally, the hind gut is separated from the proctodaeum by the cloacal membrane. At a later stage of development, these membranes disappear, and the gut opens to the exterior at its two ends.
While the gut is being formed, the vascular system of the embryo undergoes considerable development. A midline artery, the dorsal artery is established and gives off a series of branches to the gut and only three of them remain; one for the foregut, one for the midgut and one for the hind gut. They are celiac, superior mesenteric and inferior mesenteric respectively.
Gradually the midgut becomes tubular as the communication between the midgut and the yolk sac becomes narrowed. Thereafter the midgut assumes the form of a loop. The superior mesenteric artery now runs in the mesentery of this loop to its apex. The loop can therefore, be said to have a proximal or prearterial segment and a distal or post arterial segment. A bud (called caecal bud) soon arises from the post arterial segment very near the apex of the loop.
The ventral subdivision of the cloaca is now called the primitive urogenital sinus and gives origin to some parts of the urogenital system. The dorsal part is called 49
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the primitive rectum. It forms the rectum and part of the anal canal. The urorectal septum grows towards the cloacal membrane and eventually fuses with it. The cloacal membrane is now divided into a ventral urogenital membrane, related to the urogenital sinus, and a dorsal anal membrane related to the rectum. Mesoderm around the anal membrane becomes heaped up with result that the anal membrane comes to lie at the bottom of a pit called anal pit or proctodaeum. The anal pit contributes to the formation of the anal canal.
Derivatives of foregut - · Part of the floor of the mouth, including the tongue · Pharynx · Various derivatives of pharyngeal pouches and the thyroid · Oesophagus · Stomach · Duodenum : whole of the superior (1st ) part and upper half of the descending (2nd ) part · Liver and extra biliary system · Pancreas · Respiratory system Derivatives of midgut - · Duodenum :descending (2nd ) part distal to the major papilla; horizontal (3rd ) and ascending (4th )parts · Jejunum · Ileum · Caecum and appendix · Ascending colon · Right 2/3rd of the transverse colon
Derivatives of hindgut - · Left 1/3rd of the transverse colon · Descending and pelvic colon · Rectum · Upper part of anal canal · Parts of urogenital system derived from the primitive urogenital sinus
At this stage, it may be noted that endoderm of the foregut, midgut and hind gut gives rise only to the epithelial lining of the intestinal tract. The smooth muscle, connective tissue and peritoneum are derived from the splanchanopleuric mesoderm.
The rectum is derived from the primitive rectum, i.e. the dorsal subdivision of the cloaca. According to some authorities the upper part of the rectum is derived from the hind gut proximal to the cloaca
The anal canal is formed partly from the endoderm of the primitive rectum and partly from the ectoderm of the anal pit or proctodaeum. The line of junction of the endodermal and ectodermal parts is represented by the anal valves (Pectinate line). 50
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ANATOMY OF THE ANUS AND RECTUM
THE ANUS The anus is the outlet of the gastro-intestinal tract. (Fig. 1) It is one and half inches long in adult and in empty condition its lumen has the form of an anteroposterior slit in its resting period. It is expandable, conforming to the size and shape of the fecal content, and it normally varies from 1.2 to 3.5 cm in diameter in the act of defecation. The anus is surrounded by the subcutaneous muscle of the external sphincter (Fig. 2). The anal canal measures from 1.5- 2.5 cm anteriorly in length, 2-3 cm in length laterally, and 3-4 cm in length posteriorly.
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Figure 1: The rectum and anal canal.
Figure 2: The anus, showing the subcutaneous muscle
Fibers from the conjoined longitudinal muscle sphincter (Fig. 3) and its fibro elastic extensions pass into, through and around the subpecten with its glands, lymphatics and capillary network that is of great importance in anorectal suppurative processes. This is the zone of anastamoses between the superior haemorrhoidal and inferior haemorrhoidal plexuses, 53
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and to a lesser extent, the middle haemorrhoidal. The pecten's vascular anastamosis drains freely to either the portal or caval systems. Changes in the nerve supply and lymphatic drainage, also takes place at this zone. The pecten marks the area of greatest narrowing of this region.
Figure 3: Conjoined longitudinal and corrugator cutis ani muscles.
The Anorectal Line
The anorectal line (dentate, pectinate, valvular, papillary etc.) marks the upper irregular margin of the pecten (Fig. 3). Anal papillae are more often absent, but when present, they do not usually arise from the free edges of the anal valves or crypts. They correspond usually to the rectal columns of Morgagni (Fig. 4). The tips of the papillae frequently project above the lower margins of the rectal columns and are referred to as anal papillae.
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Figure 4: Papillae, crypts and Morgagnian columns
The anal crypts (Fig. 4) are tiny recesses projected between adjacent anal columns and behind the anal valves. They vary in number, depth, and shape. The more constant and larger crypts are usually just lateral to the posterior commissure and are regularly described as an etiological factor in anal fissure and fistulae. The blind ends of the crypts extend into the pecten and the proximal open ends are directed toward the rectum.
The Anal Valves The so-called anal valves are folds of squamous epithelium bridging adjacent anal columns from the free inner wall of anal crypts (Fig. 4). Histologically, the valves are thickened or cornified epidermis, which becomes continuous with the rectal columnar epithelium projected distally between the anal columns into the blind end of the crypts.
Fasciae and Relations Anteriorly in the male the anal canal is in relation with the perineal body and the accumulated concentrations of fascia at this point. From below and upward, these include the superficial and deep layers of the superficial fascia, Colle’s Fascia, at its attachment to the posterior margin of the triangular ligament, in which lie the adjoining superficial transverse perineal muscles of the bulb of the urethra, the superficial and deep layers of the triangular ligament, and finally, the rectourethralis muscle, forming the floor of the prerectal space.
In the female, the anal canal lies posteriorly in relation to the sphincter vaginae (Bulbocavernosis) muscle and the ill-defined posterior margin of the triangular ligament, the rectovaginal muscle, which forms the floor of the rectovaginal space (septum), or the prerectal space which is located just above the deep portion of the external sphincter.
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Laterally, the anal canal, covered by anal fascia, comes into relation with the wider ischiorectal fossae with its fibro-cellular matrix. Posteriorly, the anal canal is in relation with the anococcygeal body, which through its muscular and fascial reflections, contributes materially to structural support.
THE RECTUM
The rectum is the distal part of the large gut beginning from the sigmoid colon and ends at the anorectal junction. It may be described as extending from the level of the third sacral vertebral body to the anorectal line. The third sacral corresponds to the termination of a definite mesentery; it marks the point at which there is a change in the blood supply; the level at which the tinea of the sigmoid spread out to reinforce the longitudinal muscle coat; it corresponds to the site of the rectal narrowing to join the sigmoid; it marks the change in color, the capillary pattern the rugosity of the rectal mucosa. The rectum varies from 10-15 cm (12 cm or 5 in.) in length, while the circumference varies from 15 cm at the recto sigmoid junction, to 35 cm or more at its widest ampullary portion.
From the functional and endoscopic points of view, it may be divided into the sphincteric and ampullary portions. The sphincteric portion corresponds to the annulus haemorrhoidalis, surrounded by the levator ani and the fascial collar from the supra-anal fascia. The ampullary portion extends from the third sacral to the pelvic diaphragm at the insertion of the levator ani.
The ampulla of the rectum may be roughly pear shaped or balloon shaped. Longitudinally, the rectum conforms to the sacral curve. It presents two anteroposterior curves – the sacral flexure and the perineal flexure and three lateral curvatures, which may be quite prominent, and correspond to the indentures opposite the rectal valves. The adult rectum has four well-defined coats: Mucous, Submucous, Muscularis (circular and longitudinal), and Serous (Fig. 6).
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Figure 6: Coats of the rectum. The Columns of Morgagni (Rectal Columns)
These are mucosal longitudinal folds formed in the bulbus analis of the primitive rectum and persist as the rectal columns of Morgagni (Fig. 4). These columns act as accommodations for contractions and dilations of the anal canal and the sphincteric portions of the rectum.
Histologically, these consist of a somewhat denser muscularis mucosa, with richer lymphatics, vascular, and nerve supply than those of the adjacent intervening rectal wall. Between the columns are the so-called sinuses of Morgagni, which are directly continuous with the crypts.
The Mucosa
The mucosa of the rectum (Fig. 6) is thick, darker and somewhat more highly vascularized than any other mucosa in the gastro-intestinal tract. It is more mobile and has a particularly well-developed glandular apparatus, consisting of the mucigenous tubular glands (Lieberkuhn). The epithelial surface of the rectal mucosa is covered by a layer of stratified columnar cells, which assumes a cuboid shape as they go proximally. The mucosa contains abundant lymph follicles situated between the glands of Lieberkuhn. The syncytial or intrafollicular tissue between the glands conveys the lymphatics, nerve plexuses and vascular supply. The deep anal intramuscular glands are found at the anorectal junction.
The Submucosa (Muscularis mucosa) 57
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In this region (Fig. 6), the layer underlying the columns of Morgagni, the bulbus terminalis of the superior haemorrhoidal arteries and veins ramify in a supportive syncytial network of elastic and connective tissue, forming the internal or superior haemorrhoidal plexus. This arrangement permits considerable mobility of the area, and at the same time predisposes it to arteriovenous dilation and redundancy. It contains some longitudinal muscle fibers and is particularly rich in lymphatic and terminal nerve fibers and plexuses.
The Musculature of the Rectum
The rectum like the colon has inner circular and outer longitudinal layers of muscle (Fig. 6). The inner circular layer has a wing-like arrangement in which successive muscular bundles sweep fan-like from the indentations, corresponding to the valves over the lateral bulb-like expansions of the rectum. At its lower extremity, about 3-4 cm from the anal margin, the internal muscle becomes thicker and finally terminates in the well defined internal anal sphincter, which is partially encircled by the deeper layers of the external sphincter.
The outer longitudinal tunic of the rectum is formed by an expansion of the colonic tinea at the termination of the sigmoid colon. The expansion of the tinea forms a more or less diffuse fibro muscular coat, which continues down on the rectum as definite anterior and posterior banks. (Fig. 5) These become more muscular at the anorectal junction and fuse with the rectococcygeus, rectourethralis, and rectovaginalis. At the levator-rectal junction, the longitudinal muscle joins with, and is reinforced by the fibroelastic extensions from the levator, forming the conjoined longitudinal muscle. The rectal valves appear to be points of anchorage for muscle coordination.
The Serous Coat
The peritoneal coat (Fig. 6) is contained in this coat and continues from the sigmoid, is reflected over the anterior surface of the rectum, and into the interval between the bladder and uterus, forming the rectovesical or uterine pouches. Laterally the peritoneal folds are reflected diagonally upward and backward to form the Para rectal fossae and the leaves of the mesorectum and sigmoid. Anteriorly, they form the Para vesicular fossae.
The Rectal Valves
The rectal valves are crescentic plications, which have a definite structure, including the circular muscle coat of the bowel wall. In the strict sense they are not valves, and the degree to which they are able to function as such, is still debatable. Occasionally, the valves are absent. The valves are quite variable in number, location and degree of development. Usually there are three: an inferior, middle and superior but occasionally there are five. The inferior valve is usually located in the left posterior quadrant from 2.5 to 3.5 cm above the anal margin. The middle valve, usually more prominent and more constant in location, is situated over the base of the bladder or a little to the right, about 5-9 cm from the anal margin. It 58
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is referred to as the plica transversalis of Kohlrousch. The superior valve lies 3-4 cm above the middle valve.
Figure 7: Houston’s valves According to Stanton, Houston described the rectal valves which bear his name. These valves are reflections of the rectal mucosa, which contain some fibers of the circular muscle coat of the rectal wall. They lie obliquely and transverse to the length of the rectum and project into the length of the rectal lumen (Fig. 7). Their purpose seems to be, to serve as steps or spiral supports to modify the flow of the feces as they descend into the lower rectum. There are usually three, sometimes four, Houston’s valves. The lowest valve is located to the left of the midline and extends somewhat anteriorly. It is a convenient landmark in that it marks the usual limit of the downward reflection of the peritoneum anteriorly. The next valve is on the right side. This valve is said by some authorities to be on the level of the pouch of Douglas in the female, and the rectovesical pouch in the male.
The Third Sphincter (Sphincter of O’Beirne)
At a distance varying from 2-3 cm above the superior valve, the lumen of the rectum decreases in caliber to conform to that of the sigmoid (recto-sigmoid junction). At the site of this narrowing, a more or less definite increase in the circular muscular coat of the bowel is regularly described as the third sphincter, or the Sphincter of O'Beirne, having a special function in the act of defecation. It is not a true sphincter, but similar in action.
The External Sphincter
The external sphincter is formed by three striated muscles (Fig. 8): 1. The Subcutaneous
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2. The Superficialis
3. The Profundus
Figure 8: Coronal section showing anorectal muscles.
The Subcutaneous Muscle
This portion of the external sphincter (Fig. 9) is situated immediately below the transitional anal skin (transiderm). The bulk of the muscle is usually annular and disposed somewhat to or on the same longitudinal plane with the internal sphincter. It forms the lower wall of the anal canal. Occasionally it presents small posterior extensions, continuous with the strong converging legs of the superficialis muscle. Anteriorly, it may decussate with the bulbocavernosis and the retractor scroti. In the female anteriorly, it is continuous with the sphincter vaginae.
The upper and inner margin is separated from the lower edges of the internal sphincter by prominent insertions of the fibroelastic extensions of the conjoined longitudinal muscle. This forms the intersphincteric line. The subcutaneous muscle lies in a
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septal network formed by the fibro-elastic muscle, and interweaves with the subcutaneous, presenting support. These terminal extensions into the skin form the corrugator cutis ani.
The Superficialis Muscle
This is an elliptical band of muscle fibers which embraces the anal canal at the level of the internal sphincter. It is the largest, longest and strongest portion. Arising from the sides of the coccyx and forming the important muscular component of the anococcygeal body, its diverging halves surround the mid-portion of the anal canal. In the male anteriorly, they converge and insert into the central tendinous raphe. In the female, they diverge and fuse with the sphincter vaginae. Anteriorly also, crossing fibers extend laterally into the fascial shelf and attach to the ischial tuberosity and adjacent fascia. In both sexes, the anterior and posterior communicating spaces extend directly above the superficialis fibers, and below the profundus muscle.
The Profundus Muscle
This portion of the external sphincter (Fig. 9) is situated immediately above the superficialis muscle. The fibers are usually annular. Occasionally, uncrossed fibers extend posteriorly to reach the anococcygeal ligament. Anteriorly, the profundus forms the upper margin of the anorectal muscle ring, but posteriorly the puborectalis muscle forms the upper margin of this ring. The profundus lies in close relation to the legs of the levator and a common crossed arrangement of the entire muscle, extends to the opposite ischial tuberosity on either side.
The corrugator cutis ani muscle This muscle (Fig. 8) represents the terminal insertions of the fibro-elastic extensions of the longitudinal muscle into the anal canal and perianal skin. The extensions seem to penetrate the substance of the subcutaneous muscle as well as passing on either side of this muscle.
The internal sphincter The terminal portion of the circular muscle coat of the rectum gradually thickens to become the component of the internal sphincter. This muscle is surrounded by the superficialis portion of the external sphincter and forms the en tire inner muscular layer of the wall of the anal canal (Fig. 8). Immediately below its lower margin, the internal sphincter is separated from the upper border of the subcutaneous by the prominent insertions of the longitudinal muscle, forming the intermuscular septum of the intersphincteric line. Overlying the internal sphincter is the pecten, covered by squamous epithelium with subjacent areolar tissue containing lymphatics, crypts, preformed anal glands, capillaries and nerves.
The longitudinal muscle An attenuation of the anterior and posterior longitudinal bands and the tinea of the sigmoid form the longitudinal muscle coat of the rectum, which spread out to surround the 61
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inner circular muscle coat. At the anorectal junction, the longitudinal coat becomes fibro-elastic in character, fuses with the levator and fascial extensions and becomes the longitudinal muscle (Fig. 10). This fascial arrangement fixes and protects the anal canal and acts as a tendon sheathe for the divisions of the anal musculature.
Milligan’s septum Milligan describes a septum of fascia, Milligan's Septum (Fig. 10), which extends from the lower border of the internal sphincter muscle and turns outward below the superficialis and above the subcutaneous muscles, to be inserted into the ischial tuberosity and the skin. Posteriorly, the septum is incomplete.
Figure 10: The Intermuscular Sulcus.
The Intermuscular Sulcus (Fig. 10) readily palpated in the anal canal is located at the level of Milligan’s septum, in the space between the subcutaneous and internal sphincter muscles. It is a depression formed by the retraction of the skin of the canal by the pull of the insertions of the conjoined longitudinal muscle. It encircles the canal and serves as a landmark in diagnosis and treatment.
The anorectal muscle ring The levator ani muscle, in conjunction with the profundus portion of the
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external sphincter, forms a combined musculo-fascial ring which completely surrounds the anorectal junction.
Posteriorly, the puborectalis division of the levator ani reinforces the anal canal, and this forms the posterior and upper margin of the anorectal ring. Anteriorly, it decreases until there remains only a thin sheath of reflector levator fibers called the Junction of Luschka. In the anterior quadrant, only the profundus portion of the external sphincter forms the anorectal muscle ring. Damage to the puborectalis, more than any other of the anorectal muscle ring, may result in fecal incontinence. The Iliococcygeus Muscle supports the anorectal shelf in the act of defecation. The combined levators fix the pelvic structures and present a fulcrum against which increased abdominal pressure may be exerted in the acts of lifting, coughing, defecation, urination, coitus, and various other activities. By supporting and fixing the pelvic diaphragm, the levators coordinate the activity of the sphincters.
The anococcygeal ligament or body This is a firm composite musculo-fascial structure extending from the posterior aspect of the anal canal to the tip and sides of the coccyx (Fig. 12), on the lower sacrum. Into it fuses the strong insertions of the glutei muscles, the ischiococcygeus, the pubococcygeus, and the puborectalis muscles, (all at different levels) the superficialis fibers, and finally, the terminal posterior extensions of the combined longitudinal muscle and superficial fascia. Inferiorly it is bounded by the skin. Superiorly it fascial stratum is the supra anal fascia, which supports the rectal ampulla.
THE PERINEOPELVIC SPACES The perineopelvic spaces with their contained structures are directly concerned in the surgical therapy of hemorrhoids, fissure and fistulae. In several instances, the spaces are merely planes of cleavage between closely opposed fascial ensheathments of adjacent organs, as the prerectal, posterior prostatic, retrorectal, or rectovaginal spaces. These are all significant in that they are routes of infectious extensions.
The Perianal Space This space surrounds the anus and the lower third of the anal canal. Its conformation depends upon the distribution of the fibro-elastic extensions of the conjoined longitudinal muscle. Below the lower margin of the internal sphincter, a prominent group of these extensions insert into the anal canal as the intermuscular septum. From this septum the extensions continue downward below the lining of the anal canal into the perianal skin. Here they fuse with the lateral extensions passing external to the subcutaneous muscle. The inner and outer extensions roughly bound a space, which contains the subcutaneous muscle of external sphincter and the external haemorrhoidal plexus of veins with their supporting areolar network. Laterally, this space is continuous with the ischiorectal fossa. Posteriorly, it is designated as the post-anal space.
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The Submucous Space Directly above the anorectal line is the internal haemorrhoidal plexus of veins, which occupies the submucous space, extending proximally to the upper part of the columns of Morgagni. This space contains the venous radicals, a well-marked muscularis with loose areolar tissue, lymphatics, and arterial and venous capillaries. The pecten lies between the submucous and perianal spaces. This space is particularly important in haemorrhoidal formation.
The Ischiorectal Fossae Is a wedge shaped space situated one on each side of the anal canal below the pelvic diaphragm. The conformation of the ischiorectal fossae (Fig. 13) depends upon the disposition of the levator ani muscle, which forms the inner wall and roof of the ischiorectal fossae. Anteriorly, the fossae are bounded by Colle's fascia and the extensions of the fascial shelf along the posterior aspect of the superficial perineal pouch and the triangular ligament posteriorly; the boundary of these fossae is formed by the gluteus maximus muscle and the sacrotuberous ligament.
In its posteriomedial angle, the fourth sacral nerve traverses the fossae for a short distance. The perforating branches of the second and third sacral nerves leave the fossa below the gluteus, about midway between the coccyx and the ischium. Posteriorly, a thin layer of fascia separates the two fossae. Communication between them usually passes directly behind the profundus. The deepest portion of the fossae is in the area of the ischial spines. Inferiorly, the skin, reinforced by Milligan’s Septum forms the roof of the fossae. It is either incomplete posteriorly or there are anomalous defects in the area which permit entrance of infection into the fossae. Posteriolaterally is the vascular pedicle containing the inferior haemorrhoidal artery, veins and nerves. The lateral walls of the fossae are formed by the fascia of the obturator internus muscle. The fossae are smaller, narrower and deeper in the male. The average fossae are from 6- 8 cm anteroposteriorly, 2-4 cm in width, and 6-8 cm in depth. The contents then are: inferior haemorrhoidal veins and nerves crossing transversely; posteriorly, the perineal and perforating branches (cutaneous) of the pudendal plexus, and anteriorly, the posterior scrotal or labial vessels and nerves.
THE BLOOD SUPPLY TO THE ANORECTAL REGION
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Figure 17: Blood supply of the anorectal area. Fascia propria, not shown here, encases the superior haemorrhoidal vessels THE ARTERIAL SUPPLY
The vascular supply to the rectum is significant in the conception of internal hemorrhoids. The inferior mesenteric artery, below its last sigmoid branches, continues to the rectum as the superior rectal artery. It divides opposite the third sacral vertebra into right and left branches which run on each side of the rectum. Each branch breaks up at the middle of the rectum into several small branches which pierce the muscular coats and run in the anal columns up to the anal valves where they form looped anastomoses (Fig. 17). Middle rectal arteries are the anterior division of the internal iliac artery and supply the superficial muscle coats of the lower part of the rectum. Median sacral artery arising from the lower posterior part of the aorta supplies the posterior wall of the anorectal junction.
Anal canal is supplied by the Superior rectal artery (supplies the part above the pectinate line) and Inferior rectal artery (supplies the lower part of anal canal below the pectinate line.)
THE VENOUS SUPPLY
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Although the veins follow essentially the same course and give off branches corresponding to the arteries, they require additional description, because of their relation to the formation of hemorrhoids and external or perianal hematoma. The superior rectal vein begins from the internal rectal venous plexus. Several collecting veins pass upwards in the rectal sub mucosa and pierce the rectal musculature about 7.5 cm above the anus and unite to form the superior rectal vein which continues upwards as the inferior mesenteric vein. Middle rectal veins drain the muscular walls of the rectal ampulla and open into the internal iliac veins.
Internal venous rectal plexuses- lie in the submucosa of the anal canal. It drains into the superior rectal vein but communicates with the plexus. Veins are mainly presented in three anal columns situated at 3, 7 &11 o’clock positions and constitute the potential side of primary internal piles.External rectal plexus lies outside the muscular coat of the rectum and anal canal and communicate freely with the internal plexus. Anal veins are arranged radially around the anal margin.
THE LYMPHATICS Follow the veins draining the rectum an d are also divided into three groups. The lymphatic out flow from the upper half of the rectum follows the superior haemorrhoidal veins and drain into the inferior mesenteric nodes. The middle group follows the medial rectal vein and drains into the internal iliac nodes. Lymphatics of the lower part of the rectum follow the inferior rectal vein and drain into the internal iliac nodes following the internal pudendal vein.Internal iliac nodes drain from the part above the pectinate line. Medial group of superficial inguinal nodes drain from the part below the pectinate line.
THE NERVE SUPPLY
Rectum is supplied by both Sympathetic and Para sympathetic nerves through the superior rectal and inferior hypogastric plexuses. Sympathetic supply arises from the L1 &L2 and is vasoconstrictor, inhibitory to the rectal musculature and motor to the internal sphincter. Parasympathetic arises from S2, S3&S4 and is motor to the rectal musculature and inhibitory to the internal sphincter. Sensation of distention is carried y the parasympathetic nerves and pain sensations by the both sympathetic and parasympathetic nerves.
In anal canal, Sympathetic and parasympathetic supply the parts above the pectinate line. Somatic nerve supplies below the pectinate line. Sphincters- the internal sphincter is caused to contract by the sympathetic nerve and is relaxed by the parasympathetic nerve. The external sphincter is supplied by the inferior rectal nerve and by the perineal branch of the 4th sacral nerve.
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NEUROPHYSIOLOGY
Defecation Voiding of faeces is known as defecation. Faeces is formed in large intestine and stored in sigmoid colon .By reflex activity by an appropriate stimulus, it is expelled out the anus which is prevented by tonic contraction of anal sphincters in the absence of the stimulus.
Defecation Reflex
The mass movement drives the faeces into sigmoid and then to rectum. The desire for defecation occurs when some faeces enters rectum. Usually desire is elicited by the increase in the intra rectal pressure to about 20-25 cm H2O.
Usual stimulus is the intake of liquid like coffee or tea or water. The act of defecation is preceded by voluntary efforts like assuming an appropriate posture, voluntary relaxation of external sphincter and the compression of abdominal contents by voluntary contractions of abdominal muscles.
Usually rectum is empty. During the development of mass movement, the faeces is pushed into the rectum and the defecation reflex is initiated. The process of defecation involves the contraction of rectum and relaxation of internal and external sphincters.
The internal anal sphincter is made up of smooth muscle and is innervated by parasympathetic nerve fibers via pelvic nerve. The external anal sphincter is made up of skeletal muscle and controlled by somatic fibers which pass through pudental nerve. The pudental nerve always keeps the external sphincter constricted and can relax only when the pudental nerve is inhibited.
Defecation occurs by the gastro-colic reflex mediated by intrinsic nerves of gastrointestinal tract. The so-called "trigger zones" at which the initial sensory stimuli arise and produce the desire to defecate, are probably in the rectal musculature as well as in the anorectal line, which is the more important trigger zone. Here the distension of stomach by food causes contraction of rectum followed by desire for defecation. The strong contraction and relaxation of sphincters occur due to reflex mediated by parasympathetic nerves and the reflex centre is in the sacral segment of spinal cord.
PATHWAY FOR DEFECATION REFLEX:
When the rectum is distended due to faeces entry by mass movement, sensory nerve endings are stimulated and the impulses are transmitted via afferent fibers of pelvic nerve to sacral segment of spinal cord. Spinal cord, in turn sends motor impulses to the
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descending colon, sigmoid and rectum via efferent nerve fibers of pelvic nerve. The efferent impulses cause strong contraction of descending, sigmoid and rectum and relaxation of internal sphincter. Simultaneously, voluntary relaxation of external sphincter occurs. This is due to inhibition of pudental nerve by impulses arising from cerebral cortex.
On the other hand, voluntary relaxation of the anal sphincters with voluntary contraction of the colon and its complimentary muscles, with the expulsion of the rectal contents, is the actual act of defecation. In adult life, defecation is no longer a reflex, but normally becomes a voluntary act, once the summation of sensory stimuli is effected. It becomes a purely reflex act, however (sympathetico-parasympathetic), in the autonomic innervated rectum, following destruction of its cerebral connections.
Defecation may also be entirely a cortical response. Central stimulation of the Vagus produces the defecation reflex, a contraction of the rectum and a relaxation of the anal sphincters. In this regard, it may be observed that the segmental movements of the intestines are considered myogenic in origin, and the intrinsic plexuses of Meissner and Auerbach control that peristalsis. The autonomic system (sympathetic and parasympathetic) sub serves a regulatory function. Diarrhea may be entirely an intrinsic myogenic basis.
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The broad subject of constipation is directly related to the sensorimotor response of the entire gastrointestinal tract as well as those of the rectum. Failure of voiding faeces which produce discomfort is known as constipation Due to the absence of mass movement in colon, large amount of fluid is absorbed from the large intestine. So the faeces become hard and dry.
Irregular bowel habit- by inhibiting the normal defecation reflexes is the most common cause for constipation. Spasm of sigmoid colon which prevents the mobility of colon and dysfunction of myenteric plexus in large intestine which is due to absence or damage of ganglionic cells can lead to constipation. “Trigger zones" may be entirely extra rectal and in pathologic conditions, provoke a constant tenesmus leading to rectal prolapse. Further, the sensory and motor dispersions, before, after, and during the act of defecation are complex and may be reflected throughout the entire nervous system, e.g., fainting, abdominal cramping, orgasms, and neurocirculatory phenomena, are common clinical observations.
Accumulation of large quantity of faeces in the rectum leads to distention of colon. The colon is distended to a diameter of 4 to 5 inches. This condition is called Mega colon or Hirschsprung’s disease.
EXAMINATION OF A RECTAL CASE
HISTORY- The patient may present with bleeding, discharge of pus or mucous, pain, abnormality in bowel habit or prolapse.
1. Bleeding –bleeding may be the main symptom which brings the patient to the physician. Enquire about the amount of bleeding; colour of the blood lost –bright red (coming from the rectum or anal canal), dark red (coming from the ascending, transverse, descending or sigmoid colon) or black i.e. melaena (from the small intestine or higher); its relation to defaecation- whether during or independent of the act.
2. Discharge of pus or mucous- soiling of the clothes with purulent discharge coming from a sinus is the constant complaint of a patient with fistula -in –ano. In ulcerative carcinoma of the rectum the patient often passes a considerable quantity of blood stained, purulent and offensive discharge at the time of defaecation. Excessive mucous is also discharged in colitis. Crohn’s disease and colon carcinoma of the rectum.
3. Pain - All pathological conditions below the Hilton’s line are painful, but above this line they are painless so long as they remain confining within the rectal wall. Inflammation or infiltration beyond the rectal wall is likely to be painful. Enquire about the nature of pain – whether throbbing (ano rectal abscess) or sharp cutting (anal fissure) and its relation with defaecation. Pain is the main symptom of c/c fissure –in-ano. It starts with defaecation and 69
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persists for some time after the act. Uncomplicated piles are absolutely painless but when they are complicated with secondary infection or strangulation, they become painful. Carcinoma of the rectum is painless to start with. When pain appears it indicates its spread into the pelvic cellular tissue or sacral plexus (often causing bilateral sciatica).
4. Abnormality in bowel habits –patients may present with abnormal bowel movements when anything goes wrong inside the rectum and anal canal. Usually a proliferative growth in the ampulla causes a sensation of fullness in the rectum and the patient may feel his bowel has not been completely emptied after defaecation. Increasing constipation is the earliest symptom in carcinoma rectum whether occurring in pelvirectal junction, in the ampulla or in the anal canal either annular or ulcerative or proliferative variety. In ulcerative growth, mucus, pus blood and faeces accumulate overnight and the patient on rising from bed gets an urgent call to stool-this is called ‘spurious diarrhoea’. A growth in the lower part of the anal canal may alter the shape of the stool which may be either pipe stem or tape like.
5. Prolapse – if the patient complains of something coming out of the anal canal during defaecation, he is possibly suffering from prolapse, polypus or long standing internal piles. Enquire whether the prolapse that comes out with defaecation is reduced automatically after the act or has to be replaced by pushing it in. Sometimes the patient comes with prolapse remaining unreduced for two or three days. Enquire also about the length of the protruded mass. If the protrusion is slight, it is partial prolapse. If it is more than two inches in length, it is a complete prolapse or procidentia.
PAST HISTORY –enquire about the history of any constipation or alternation of diarrhea with constipation. Habitual constipation may be associated with internal piles and fissure. History of wasting may lead to weakening of rectal support which in turn responsible for the development of prolapse. Anal tag and perianal abscess are some times seen in Crohn’s disease.
FAMILY HISTORY – polyposis is recognized to be a hereditary disease. A family history may be volunteered by the patients suffering from piles, fissures, prolapse and even carcinoma of the rectum.
RECTAL EXAMINATION
Position of the patient
1. The left lateral position (Sims’) – this is the most popular position for the ano rectal examination. The patient lies on the left side. The buttocks should project over the edge of the table. Both the hips and knees are well flexed so that the knees are taken near to the chest of the patient. This position is suitable for the inspection of the perianal region and Proctoscopy.
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2. Dorsal position – the patient lies on the back with hips flexed. The examiner passes his forearm beneath the right thigh and the index finger is pushed through the anal canal. This position is popular when the patient is too ill to alter the position. It is also convenient to do bimanual examination in this position. The right index finger remains in the rectum while the left hand is on the abdomen to know the interior of the pelvis in a better way.
3. The knee-elbow position- this position is particularly suitable for palpating the prostate and seminal vesicles.
4. Right lateral position –can be chosen in the case of carcinoma at the pelvirectal junction when it tends to fall downwards and towards the anus for better palpation by the examining finger
5. Lithotomy position- the advantages of this position are that more information regarding pelvic viscera can be obtained and bimanual examination can be conveniently performed. More over a lesion high in the rectum is more likely to be felt.
It should be remembered that about 10 cm from the anus can be explored by digital examination. It cannot be emphasized too strongly that the anal region must be inspected firstly, palpated secondly and digital examination lastly.
Inspection:
This part of examination should never be omitted. Anal tags, sentinel pile, fistula -in-ano, pilonidal sinus, condyloma and carcinoma can be diagnosed by inspection alone. Further more inspection will provide with information regarding internal piles, prolapse, and pruritis ani etc. When there is a history of prolapse ask the patient to strain as he would do during defaecation, if required in the squatting position. Note the protruded mass. It should be remembered that an external pile is covered with skin where as an internal pile is covered with mucous membrane.
Palpation:
Before digital examination, palpation of the perianal region should be performed. Any tenderness or mass or local rise of temperature should be examined.
Digital examination:
The patient is instructed to lie down on his left side and asked him to breathe through his mouth A digital (finger) rectal examination is done to check for abnormalities of organs or other structures in the pelvis and lower abdomen. Helps to find out the cause of symptoms such as rectal bleeding, rectal tumors and other forms of cancer. In males, for 71
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the diagnosis of prostatic disorders, notably tumors and benign prostatic hyperplasia; for the estimation of the tonicity of the anal sphincter. It is usually done prior to a colonoscopy or Proctoscopy. At the end of the rectal examination, always look at the examining finger for presence of faeces, blood, pus or mucus.
When finger enters the rectum it should be pushed as high as possible. Information received in rectal examination can be divided into (a) with in the lumen, (b) in the wall and (c) out side the wall.
With in the lumen – if the rectum is found to be full of faeces, a complete examination of rectum is impossible. So it is a good practice to give enema before rectal examination. Any discharge or obstruction should be identified.
In the wall – on examination there is a constriction which marks the line between the external and internal sphincters and also marks the dividing line between the internal and external haemorrhoidal plexuses. Further up, the anorectal ring can be felt which approximately 3cm above the anal verge. Uncomplicated internal piles cannot be felt with the finger. Only chronically inflamed and thrombosed piles can be felt by digital examination.
Out side the wall – this is the most important part of rectal examination and more often used as diagnostic procedure than the previous section. The structures around the rectum are explored systematically by palpating anteriorly, right lateral left lateral and posteriorly.
Bimanual examination: The examination of the contents of the pelvis can be conveniently examined during rectal examination by placing another hand on the abdomen. This gives a better idea of size, shape and nature of any pelvic mass. Its immense importance in staging of bladder carcinoma is worth mentioning.
Abdominal examination:
In case of annular carcinoma at the upper part of rectum an indistinct lump may be felt at the left side of the abdomen. Examine the liver for the secondary metastasis. Note also if there is any jaundice, hard subcutaneous nodules and free fluid within the abdomen.
Lymph nodes:
Carcinomas arising from the hindgut will metastasis to the iliac group of lymph nodes. On deep palpation one may discover enlargement of these nodes particularly in thin patients.
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INVESTIGATIONS
Other investigations like colonoscopy, sigmoidoscopy and proctoscopy can be used to find out the exact cause of rectal and anal conditions by direct visualization of the interior of them and also helps in local treatment.
Colonoscopy:
Colonoscopy allows the physician to look inside the entire large intestine from the lowest part, the rectum, all the way up through the colon to the lower end of the small intestine. The procedure is used to diagnose the causes of unexplained changes in the bowel habits. It is also used to diagnose the early signs of cancer in the colon and rectum.
It enables the physician to inspect the inflamed tissues, abnormal growths, ulcers, bleeding and muscle spasm. The tube is called colonoscope which can transmit the image of inner side of colon. As the instrument is bendable, it can be moved around the curves of the colon. The scope also blows air into the colon to inflate which helps the physician to see the inner part very well. It can also be used for biopsy collection and can be used for therapeutic purpose. In case of bleeding per rectum, it can pass laser, heater probe or electrical probe or inject special medicines to the site to arrest bleeding.
Bleeding and colon puncture are the possible complications of colonoscopy. However such complications are uncommon. Colonoscopy takes 30-60 minutes.
According to the STOP COLON /RECTAL CANCER FOUNDATION, at the beginning of 50 years of age, all should have a screening colonoscopy every ten years. Even though is asymptomatic, need to be scanned. If there is any personal or family history of benign colorectal polyp, colorectal cancer, ovarian cancer, uterine cancer, breast cancer, ulcerative colitis or Chron’s disease, should have a colonoscopic screening by the age of 40.
Proctoscopy: Introduction of this instrument is in the knee-elbow position. The instrument is well lubricated and passed through the anus along the direction of anal canal i.e. upward and towards the umbilicus. Now the obturator is with drawn and the interior of the rectum and anal canal is seen with the help of the light the piles will protrude into the proctoscope as this instrument is being withdrawn. Note the position of the piles. When the patient is in the lithotomy position the piles will be corresponding to the 3, 7, &11 o’clock positions. A few secondary piles may be seen between them. C/c fissure is often situated on the midline posteriorly.
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Sigmoidoscopy: It can be supported by the contrast enema x-ray. The length of the sigmoidoscope is about 14 inches (35cm). By this instrument the whole of the rectum and a large part of the sigmoid colon can be examined.
The conventional position for introduction of this instrument is the knee-elbow position. The instrument is well lubricated and passed through the anus along the direction of anal canal i.e. upward and towards the umbilicus. As soon as the tip has entered the rectum all further introduction should be carried out under direct vision. The obturator is withdrawn; the glass eye-piece and the light carrier are fitted. Now the instrument is pushed posteriorly. While within the rectum, by circumduction movement the interior of the rectum is thoroughly inspected. Then it is pushed up into the pelvirectal junction and then into the pelvic colon. By gentle inflation of the bowel under direct vision the lumen can be made to open out in advance of the instrument. By continuing in the same manner sigmoidoscope can be passed up to its full extent so that the great part of the pelvic colon can be examined.
It is mainly used to detect any presence of any growth, ulcer, diverticula etc. The growth can be biopsied and a smear can be taken from the ulcer for bacteriological examination through this instrument. Perforation is the most frequently reported complication.
Certain contraindications of endoscopic examination are a/c toxic dilatation of colon, a/c severe ulcerative colitis, a/c diverticulitis, radiation necrosis, recent bowel anastomosis, uncooperative patients etc.
HAEMORRHOIDS
Haemorrhoids (also known as hemorrhoids or piles) are enlarged and engorged blood vessels in or around the anus. They are varicosities or swelling and inflammation of the haemorrhoidal plexus of veins situated in the loose sub mucus coat of anal canal and lower part of the rectum. They can be bleeding and non- bleeding.
Haemorrhoids are very common in women and men. About half the population has haemorrhoids by the age of 50.Hemorrhoids bother about 89% of all Americans at some time in their lives. Hemorrhoids caused Napoleon to sit side-saddle, sent President Jimmy Carter to the operating room, and benched baseball star George Brett during the 1980 World Series. Over two thirds of all healthy people reporting for physical examinations have hemorrhoids.
CLASSIFICATION OF HEMORRHOIDS
Based on aetiology :
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· Primary / idiopathic
· Secondary n Based on location
· Exernal haemorrhois
· Internal haemorrhoids
Grade 1
Grade 2
Grade 3
Grade 4
· Intero external
EXTERNAL HEMORRHOIDS
Are those that occur outside of the anal verge (the distal end of the anal canal) under the skin. This is less common than internal haemorrhoids. As external haemorrhoid is like a small lump that develops on the outside edge of the anus sometimes called as perianal haematoma .They are sometimes painful, and can be accompanied by swelling and irritation. Itching, although often thought to be a symptom of external hemorrhoids, is more commonly due to skin irritation. If the vein ruptures and a blood clot develops, the hemorrhoid becomes a thrombosed hemorrhoid. A small clot in the perianal subcutaneous tissue can be seen superficial to the corrugator cutis anti muscle. This condition is due to back pressure on the anal venule consequent upon straining at stool, coughing or lifting heavy weight. The condition appears suddenly and is very painful.
The pain due to a thrombosed external haemorrhoid usually peaks after 48-72 hours, and then gradually goes away over 7-10 days. It may be seen lateral to the anal margin as tense and tender swelling. A thrombosed external haemorrhoid may bleed a little for a few days. If untreated, it may resolve by itself or may suppurate or may fibrose and gradually shrinks to become a small skin-tag.
INTERNAL HEMORRHOIDS
Are those that occur inside the anus or rectum above the Hilton’s line and it is covered by mucous membrane. As this area lacks pain receptors, internal hemorrhoids are
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usually not painful and most people are not aware that they have them. Internal hemorrhoids, however, may bleed when irritated.
Internal haemorrhoids can be divided into two main types
(a) Vascular haemorrhoids in which there is extensive dilatation of the terminal superior haemorrhoidal venus plexus –commonly found in younger individuals particularly men
(b) Mucosal haemorrhoids –in which there is sliding down of the thickened mucus membrane which conceals the underlying veins.
Piles may occur at all ages, but are uncommon below the age of twenty years barring piles secondary to vascular malformation which may occur in children.
For practical purpose internal piles can be divided into four degrees:
Grade 1 or 1st degree haemorrhoids – are those in which hypertrophy of the internal haemorrhoidal venus plexus remains entirely within the anal canal as the mucosal suspensary ligaments remain intact. Patients in this stage usually present with rectal bleeding and discomfort or irritation. Bleeding is the predominant symptom which is of bright blood and occurs during defaecation as splash in the pan. It may continue for months or years. They are small swellings on the inside lining of the back passage which cannot be seen or felt from outside the anus. Grade 1 haemorrhoids are common. In some people they enlarge further to grade 2 or more.
Grade 2 or 2nd degree haemorrhoids – occur when the internal haemorrhoids further hypertrophy and the mucosal suspensary ligaments become lax and the piles will descend so that they prolapse during defecation but spontaneous reduction takes place afterwards. There may be small skin tag, some mucus discharge, soreness and irritation.
Grade 3 or 3rd degree – haemorrhoids are those which prolapse during defecation but require manual replacement. It may feel one or more as small, soft lumps that hang from the anus. However, they can be pushed back inside the anus with a finger. Mucosa overlying such haemorrhoids undergoes squamous metaplasia. Mucus discharge and pruritis ani become troublesome and anaemia becomes obvious.
Grade 4 or 4th degree haemorrhoids – permanently hang down from within the anus, and cannot be pushed them back inside. They sometimes become quite large. Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolapsed and strangulated hemorrhoids:
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Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are pushed outside of the anus.
If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outside of the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a strangulated hemorrhoid.
Some people have internal and external haemorrhoids at the same time. This condition where both varieties co-exist is called intero-external haemorrhoids.
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HAEMORRHOIDS
Bleeding Haemorrhoids Strangulated Haemorrhoids
Haemorrhoids with anal tag
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Internal hemorrhoids occur higher up in the anal canal, out of sight. Bleeding is the most common symptom of
internal hemorrhoids, and often the only one in mild cases.
External hemorrhoids are visible-occurring out side the anus. They are basically skin-covered veins that have ballooned and appear blue. Usually they appear without any symptoms. When inflamed, however, they become red and tender.
Sometimes, internal hemorrhoids will come through the anal opening when straining to move your bowels. This is called a prolapsed internal hemorrhoid; it is often difficult to ease back into the rectum, and is usually quite painful.
When a blood clot forms inside an external hemorrhoid, it often causes Severe pain. This thrombosed external
hemorrhoid can be felt as a firm, tender mass in the anal area, about the size of a pea.
PREVALENCE
Hemorrhoids are very common in both male and female. It is estimated that approximately one half of the population have haemorrhoids by the age of 50. However, only a small number seek medical treatment. They are also common among pregnant women. The pressure exerted by the growing foetus as well as the hormonal changes cause the haemorrhoidal vessels to enlarge. These vessels also undergo severe pressure during child birth. For most women however, haemorrhoids caused by pregnancy are a temporary problem.
AETIOLOGY : The causes of hemorrhoids include: i) Hereditary – it is often seen in members of the same family that there must be a genetic predisposition such as weak rectal vein walls and/or valves. Due to poor muscle tone or poor posture, straining during bowel movements can cause too much pressure on the rectal veins. 79
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ii) Anatomical – it has long been suggested that internal pile is a natural consequence of adaptation of erect posture by mankind, (a) Absence of valves in the superior haemorrhoidal veins, (b) The veins pass through the rectal musculature 10 cm above the anus will cause occlusion of the veins and congestion during defecation, (c) The radicles of superior rectal vein lie unsupported in the loose submucous connective tissue of the rectum. iii) Exciting factors – Parks suggested straining to expel the constipated stool causes dilatation of the venous plexus. Once dilatation of the venous plexus as well as the partial prolapse would occur with each bowel movement it would stretch the mucosal suspensary ligament. Over purgation and diarrhoea of colitis, dysentery, enteritis etc. aggravate the latent haemorrhoids. Additional factors that can influence the course of hemorrhoids especially for those with a genetic predisposition are obesity and a sedentary lifestyle.
iv)Physiological causes –some surgeons more recently have regarded the extensive venous plexus of the upper anal canal as physiological. The pathology of so called haemorrhoidal plexus is infact a corpus cavernosum with direct arteriovenous communication. This plexus is termed corpus cavernosum rectum, which is a normal constituent in the upper third of the anal canal. Hyperplasia of the corpus cavernosum rectum may result from failure of mechanism controlling the arterio venous shunts producing superior haemorrhoidal veins varicosity and thus haemorrhoids. v) Squatting- Using a squat toilet has been hypothesized to reduce straining and therefore reduce the occurrence of hemorrhoids. However, the medical research into this subject is scarce, and there has been no definite proof for this hypothesis. Hemorrhoids are very rare in nations where people squat to defecate, but this epidemiological argument doesn't necessarily prove a causal relationship. vi) Diet
1. Insufficient hydration (caused by not drinking enough water, or by drinking too much diuretic liquid such as coffee or cola) can cause a hard stool, which can lead to haemorrhoidal irritation.
2. An excess of lactic acid in the stool, a product of excessive consumption of milk products such as cheese, can cause irritation and so a reduction of consumption can bring relief.
3. Vitamin E deficiency is also a common cause.
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4. Excessive alcohol consumption can cause diarrhea which in turn can cause haemorrhoidal irritation.
5. They are said to be more common in countries where the diet has traditionally been more processed and low in fibre.
SECONDARY HAEMORRHOIDS
The main contributory causes are those things that cause to raise the pressure in the abdomen. This causes the blood vessels to swell and become engorged.
Those chronically straining with constipation. Its causes should be excluded, otherwise the condition will recur.
After or during pregnancy -The pressure of the foetus in the abdomen, as well as hormonal changes, cause the haemorrhoidal vessels to enlarge. These vessels are also placed under severe pressure during childbirth.Here; the baby may actually press on the main blood vessel that returns blood to the heart (the vena cava).
Carcinoma of the rectum –compresses the superior rectal veins causing haemorrhoids.
Uterine tumors may compress the veins to cause haemorrhoids
Difficulty in micturition – stricture of urethra or enlarged prostate will cause increase in intra abdominal pressure and thereby increase in venous pressure to cause haemorrhoids.
Hemorrhoids may also result from portal hypertension because of the portacaval anastomoses.
People with heavy lifting jobs.
PATHOGENESIS Haemorrhoids are actually blood vessels which are always present. Haemorrhoids are arteriovenous vascular networks situated below the lower mucous membrane of the intestine and under the skin at the extremity of the large intestine as well as in the upper area of the anal canal. These vascular networks cover the closing muscle of the anus allowing maximum elasticity and additional occlusion for a perfect closure. Hence, the continence of faecal matter, secretions and gases. Haemorrhoid complaints however, are the result of blood congestion which provokes an enlargement and inflammation of these vessels. This condition shows various stages of seriousness.
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n First Stage: The enlargement of the vascular networks prevents them from closing the anal orifice. The anal region is slightly painful. An external examination or palpation does not reveal anything except a slight swelling with occasional itching or secretion. n Second Stage: the vascular nodules protrude and then retract spontaneously during bowel movement. This stage is characterized by strong itching, a burning feeling, mucous and bright red blood discharges. n Third Stage: the vascular nodules lose their retractility and have to be manually reinserted into the anus. At this stage there could be anal fissures i.e. lesions of the mucous membrane. n Fourth Stage: the nodules and vascular masses become very painful and cannot be reinserted. A considerable swelling prevents the blood from flowing back, a condition which could result in haemorrhoidal thrombosis, abscesses, ulcers and gangrene leading possibly to a septic thrombophlebitis of the portal vein. Beware, this stage could be fatal
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PATHOLOGY
Haemorrhoids are a condition in which the poorly supported haemorrhoidal veins become dilated and varicose. Internal haemorrhoids are frequently arranged at 3, 7, & 11 o’clock position with the patient in lithotomy position. This distribution has been attributed to the arterial supply of anus, where by there are two sub divisions of the right branch of superior rectal artery arranged in right anterior and right posterior positions and the left branch remains single in the left lateral position. In between these three primary internal haemorrhoids there may be smaller
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secondary haemorrhoids. SHAPE \* MERGEFORMAT
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Each principal haemorrhoid can be divided into three parts
1. pedicle
2. body of internal haemorrhoid
3. associated external haemorrhoid
The pedicle is situated in the rectum just above the anorectal ring. It is covered with pale pink mucosa through it a large tributary of the superior rectal vein can be seen. Occasionally a pulsating artery may be felt at the pedicle.
After the pedicle, the body of the internal haemorrhoid continues distally and ends at the dentate line. The body is covered with bright red or purple mucous membrane. Haemorrhoids occurring above the dentate line are called internal haemorrhoids and those occurring below the dentate line are called external haemorrhoids.
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Associated external haemorrhoid lies in between the dentate line and the anal margin and is covered by the skin. The blue vein can be seen through the skin. Associated external haemorrhoid is present in long continued cases of internal haemorrhoids.
Histologically haemorrhoids consist of dilated veins in the mucosa and submucosa – cluster of dilated veins may resemble a cavernous angioma. It is covered by mucous membrane and skin. Infection is frequent with accompanying phlebitis and thrombosis known as an “attack of piles”. The thrombus may become fibrosed, a condition of spontaneous recovery. In rare cases the infected thrombus may become broken up and form septic emboli, which are carried to liver and form abscess there. The tissue around the haemorrhoids become fibrosed, and is often infiltrated with chronic inflammatory cells. Apart from thrombophlebitis the principal symptom is repeated haemorrhage during defecation, which may lead to marked secondary anaemia.
CLINICAL FEATURES
Bleeding – the principal and earliest symptom especially after moving the bowels. At first it is slight, bright red, painless and occurs along with defaecation. The patient complaints that it splashes in the pan as the stool comes out. This may continue for months or even years. Along with this many surgeons believe that haemorrhoids can be divided into two main types
1) Vascular haemorrhoids
2) Mucosal haemorrhoids in which the thickened mucous membrane slides downwards. This mucous haemorrhoid along with the prolonged dilatation of the internal haemorrhoids may also cause 3rd degree or prolapsed haemorrhoids.
Prolapse – is a later symptom. In the beginning prolapse is minimal and occurs only at stool and reduction is spontaneous. As time goes on, it may not reduce themselves but have to be replaced digitally by the patient. Still later prolapse occur during the day apart from defecation often when the patient s are tired or exert them selves. It will cause a discomfort and a feeling of heaviness in the rectum but are not usually acutely painful.
According to prolapse, haemorrhoids can be divided into four degrees
FIRST DEGREE- haemorrhoids do not come out of the anus
SECOND DEGREE- - haemorrhoids come out only during defecation and are reduced spontaneously after defecation
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THIRD DEGREE- haemorrhoids come out only during defecation and do not return by themselves, but need to be replaced manually and then they stay reduced.
FOURTH DEGREE- haemorrhoids that are permanently prolapse. At this stage great discomfort is complained of with a feeling of heaviness in the rectum.
Discharge – a mucous discharge is a frequent symptom of prolapsed haemorrhoids which softens and excoriates the skin at the anus and is due to engorged mucous membrane. Pruritis ani will be caused by such mucus discharge.
Pain – is absent unless complications supervenes.
Itching (Pruritis ani) – Although itching of the anus is not a symptom of haemorrhoids, if they are painful it may make it difficult to keep the area clean, which can lead to itching from mucous discharge
Anaemia - Very rarely, blood loss from haemorrhoids can cause anaemia, and is seen in long standing cases of haemorrhoids with profuse and persistent bleeding but this is almost never severe and can be avoided by early treatment.
Miscellaneous symptoms – like there is often a feeling of something coming down, or a bulge or lump at the anus. The feeling of incompletely emptying the bowels even after a bowel motion .These symptoms occur with both internal and external haemorrhoids. If haemorrhoids are external, will have a painful swelling or lump around the anus. They may be gently pushed back inside the anus with finger or they may go back in on their own. However, an internal haemorrhoid may protrude through the anus as bunch of grapes and recedes back. Sometimes the mass gets prolapsed and protrudes always outside the anus.
On inspection – internal haemorrhoid without prolapse will no show any abnormal features. During second and third degree haemorrhoids, Internal haemorrhoid may be seen only when the patient strains and that too transiently and the prolapse disappears after the straining is over. During fourth degree, the prolapsed piles can be seen in 3, 7, 11 o’clock positions.
On digital examination cannot feel an uncomplicated internal pile unless it is thrombosed.
Proctoscopy – will reveal the internal pile as described in the pathology. The proctoscope is introduced as far as it does. The obturator is then removed and with an illuminator the inside of the anal canal is visualized. The proctoscope is now withdrawn slowly and the internal haemorrhoids will be seen bulging into the proctoscope.
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COMPLICATIONS
The two main complications of haemorrhoids are excessive bleeding and thrombosis. Besides these there are a few complications which may occur in a haemorrhoid and are described below.
Haemorrhage- it occurs particularly in the first degree haemorrhoid and in the early stages of the second degree haemorrhoids. The bleeding occurs mainly externally but it may continue internally after the bleeding haemorrhoids has retracted or has been returned. In these circumstances the rectum is found to contain blood.
Strangulation- One or more of the internal haemorrhoids prolapse and become gripped by the external sphincters. Further congestion follows because the venous return is impeded. Strangulation is accompanied by considerable pain unless the internal haemorrhoids can be reduced within an hour or two. Strangulation is followed by thrombosis.
Thrombosis- The affected haemorrhoid or haemorrhoids become dark purple or black and feel solid. Considerable oedema of anal margin accompanies thrombosis. Once the thrombosis has occurred the pain of strangulation passes off, but tenderness persists.
Ulceration- Superficial ulceration of the exposed mucus membrane often accompanies strangulation with thrombosis.
Gangrene- Gangrene occurs when strangulation is sufficiently tight to constrict the arterial supply of haemorrhoid. The resulting sloughing is usually superficial and localized. Occasionally a whole haemorrhoid sloughs off leaving an ulcer, which heals gradually. Very occasionally massive gangrene extends to the mucus membrane within the anal canal and rectum and can be the cause of spreading anaerobic infection and portal pyaemia.
Fibrosis- After thrombosis, internal haemorrhoids sometimes becomes converted into fibrous tissue the fibrosed haemorrhoid is at first sessile but by repeated traction during prolapse, at defecation it becomes pedunculated and constitutes a fibrous polyp. That is readily distinguished by its white colour from an adenoma, which is bright red.
Suppuration- This is uncommon. It occurs as a result of infection of a thrombosed haemorrhoid. Throbbing pain is followed by perianal or sub- mucus abscess results.
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Pylophlebitis- Theoretically, infected haemorrhoids should be a potent cause of portal pyaemia and liver abscess. It can occur when patients with strangulated haemorrhoids are subjected to ill advised surgery and have even been reported to follow banding.
DIAGNOSIS OF HAEMORRHOIDS
Methods Of Diagnosis
1. Clinical diagnosis
- By history
- By clinical symptoms
2. Physical examination
3. Special investigation
-Proctoscopy
-Endoscopicmethod
• Sigmoidoscopy
• Colonoscopy
PHYSICAL EXAMINATON
1. Visual Examination
Visual examination of the anus and surrounding area is done for external or prolapsed hemorrhoids. Look for indications of rectal tumor, polyp, abscesses, and congenital deformity. Examine for any discharge or any inflammatory signs
Visual confirmation of hemorrhoids can be done using a medical device called an anoscope. This device is basically a hollow tube with a light attached at one end that allows the doctor to see the internal hemorrhoids, as well as polyps in the rectum
2. Digital Rectal Examination
A digital (finger) rectal examination is done to check for abnormalities of organs or other structures in the pelvis and lower abdomen. It helps to find out the cause of symptoms such as rectal bleeding. It can also collect a stool sample to test for blood in the stool. 89
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This examination may be used: for the diagnosis of rectal tumors and other forms of cancer; in males, for the diagnosis of prostatic disorders, notably tumors and benign prostatic hyperplasia; for the estimation of the tonicity of the anal sphincter, which may be useful in case of fecal incontinence or neurological diseases; in females, for gynecological palpations of internal organs for examination of the hardness and colour of the faeces (i.e. in cases of constipation, and fecal impaction); prior to a Colonoscopy or Proctoscopy.
The patient will be asked to lie on his left side on an examination couch with his knees brought up towards his chin. If finds it easier, he can lean over the back of a chair or across the examination table instead. The doctor will put on a thin vinyl or rubber glove, lubricate their gloved forefinger with gel and slide it gently into his back passage. This may be uncomfortable or embarrassing, but it should not be painful.
THE POSITION OF THE PATIENT DURING DRE.
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Normally – Rectal exam is unpleasant. The sphincter has sufficient tone to grasp the finger. Soft stools may be felt. The walls of the mucosa are smooth. The prostate gland is about 2.5 cm in length, with a medial sulcus, is firm and non-tender. Stools can be seen on the gloved finger. Men usually feel some discomfort or pain during a digital rectal exam (DRE) Most women do not find a DRE painful. People with hemorrhoids, anal fissures or other anal sores may find a DRE more painful than people without these conditions.
Abnormalities, such as organ enlargements, tissue hardening, or growths, are felt (palpated) during the examination. For men, the prostate gland may be enlarged; indicating benign prostatic hypertrophy (BPH) or inflammation of the prostate gland (prostatitis), or tumors or polyps are felt. For women, growths (such as tumors or polyps) of the cervix, uterus, or ovaries are felt. Growths such as hemorrhoids, polyps, tumors, or abscesses may be found in the lower rectum. Internal hemorrhoids may not be able to be detected. Breaks in the skin around the anus (anal fissures) may be discovered. Abnormalities of the bladder may also be felt.
Risks like slight bleeding from the rectum may occur after an examination, especially if hemorrhoids or anal fissures are present. On rare occasions, may experience a loss of consciousness (called vasovagal syncope) because of fear or pain when finger is inserted into the rectum. This is more common if you are standing up.
3. Protoscopy
Done with the instrument called proctoscope. Usually done as routine examination for visualizing the anal canal
Introduction of this instrument is in the knee-elbow position. The instrument is well lubricated and passed through the anus along the direction of anal canal i.e. upward and towards the umbilicus. Now the obturator is with drawn and the interior of the rectum and anal canal is seen with the help of the light. The piles will protrude into the proctoscope as this instrument is being withdrawn. Note the position of the piles. When the patient is in the lithotomy position the piles will be corresponding to the 3, 7, &11 o’clock positions. A few secondary piles may be seen between them. C/c fissure is often situated on the midline posteriorly
If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy can be performed. In sigmoidoscopy, the last 60cm of the colon and rectum are examined whereas in colonoscopy the entire bowel is examined.
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4. Sigmoidoscopy
It can be supported by the contrast enema x-ray. The length of the sigmoidoscope is about 14 inches (35cm). By this instrument the whole of the rectum and a large part of the sigmoid colon can be examined. The conventional position for introduction of this instrument is the knee-elbow position.
The instrument is well lubricated and passed through the anus along the direction of anal canal i.e. upward and towards the umbilicus. As soon as the tip has entered the rectum all further introduction should be carried out under direct vision. The obturator is withdrawn; the glass eye-piece and the light carrier are fitted. Now the instrument is pushed posteriorly. While within the rectum, by circumduction movement the interior of the rectum is thoroughly inspected. Then it is pushed up into the pelvirectal junction and then into the pelvic colon. By gentle inflation of the bowel under direct vision the lumen can be made to open out in advance of the instrument. By continuing in the same manner sigmoidoscope can be passed up to its full extent so that the great part of the pelvic colon can be examined.
It is mainly used to detect any presence of any growth, ulcer, diverticula etc. The growth can be biopsied and a smear can be taken from the ulcer for bacteriological examination through this instrument. Perforation is the most frequently reported complication.
PROCTOSCOPES
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DIFFERENTIAL DIAGNOSIS
Foreign bodies – they include those that have been introduced through the anus and those that have been swallowed. For example fish bone, pins, needles, splinters of wood etc.
Abscess- Submucous abscess gives rise to more or less elongated, smooth elastic swelling in the rectal wall. It is intensely tender. The mucus membrane may feel hot and pits on pressure. If the abscess has burst during examination, the finger tip on withdrawal may be covered with pus.
Granular proctitis- this condition is often mistaken for piles because its predominant symptom is bleeding giving rise to hyper vascular dull appearance of the rectal mucosa when viewed through the proctoscope.
Polyp – a polyp may not be easy to feel, because its consistency is much the same as that of the mucus membrane and because its pedicle may allow free movement, it may be mistaken for a small mass of faeces. The best way to fix this growth is to sweep the finger around the whole circumference of the rectum up to the highest point attainable. The growth is then arrested by the pedicle and the finger can be hooked around it and make it protrude through the anus.
Ulcers – it can be rarely felt with the finger unless it may be chronically inflamed or malignant. They may be tuberculous, gummatous, traumatic or due to ulcerative colitis. They must be viewed with the proctoscope or the sigmoidoscope.
Carcinoma – rectal carcinoma may occur within twenties or even earlier. The commonest site is in the upper half of the rectum or recto sigmoid junction .The clinical features are suggestive. The patient describes a recent and a progressive alteration in bowel habits, either constipation or diarrhoea. Blood and mucus may be noticed. Wasting is not so common. Dull aching pain in the rectum and at the bottom of the back may be felt. Biopsy will confirm the diagnosis.
Villous tumor of the rectum – they are confined to the mucus membrane and may attain the size of an orange. History reveals the passage of large quantities of pure mucus per rectum over many years and occasional large haemorrhage in a patient who is other wise well and not constipated. To the finger they feel raised from the surrounding mucus membrane, soft and almost jelly like and freely movable.
Intussusception – occasionally the apex of the intussusception may come down so far as to be felt per rectum. This condition is associated with the passage of blood and mucus. This occurs mainly in children especially at the age of nine months and causes intestinal obstruction.
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Stricture –this may be present at the anal orifice at the level of the upper border of the internal sphincter or 7-8cm up the rectum. It may be annular or tubular. There will be no bleeding unless the finger is forced through the stenosis and the mucus membrane is torn
Fistula –in-ano – it may be either recto vaginal or rectovesical whether congenital or acquired. It may be felt with the finger. The passing of urine or faeces through abnormal passages indicate the complaint
Fissure-in-ano – is a very common and painful condition occurring most commonly in the midline posteriorly. In males, fissures are most commonly seen in posteriorly (90%) and less commonly anteriorly (10%). In females it is of in 60:40 %ratios. Usually it is seen between30 and 50 years of age. Constipation, spasm of internal sphincter and previous operation stenosis can lead to fissure–in-ano. Pain is the most predominant symptom which is of sharp, biting, burning and intolerable in nature. Bleeding varies, usually as streaks on the out side of stool or spots noted on toilet tissue. Slight discharge may accompany a fully established c/c fissure. Pruritis ani may be seen. A typical fissure –in-ano will have a hypertrophied anal papilla in the upper end and a sentinel pile at its lower end with a canoe shaped ulcer in between.
Rectal prolapse – this condition is seen at the extremes of life- in children beween 1 to 3 years and elderly after 40 years of age. Women are more commonly affected than males. The main complaint is that something coming out per rectum during defaecation. Haemorrhoids or polyp can be easily diagnosed. Proctoscopy will help to exclude other pathologies.
Condyloma acuminata – otherwise known as anal warts, are benign lesions seen around the anus. The extent of the disease varies to a few small warts to an extensive mass occluding the anal canal. Bleeding, itching and pruritis ani are the common symptoms. On examination, soft papillary appearance becomes obvious without any induration. Multiple biopsies and histological examination should be done to exclude associated squamous cell carcinoma.
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DIFFERENTIAL DIAGNOSIS
NORMAL ANUS ANAL FISTULA
ANAL TAG ANAL Fissure
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ANAL POLYP C/C SOLITARY ULCER
PERIANAL ABSCESS PERIANAL CONDYLOMATA
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ANAL CARCINOMA
HYPERTROPHIED PAPILLA RECTAL PROLAPSE
TREATMENTS OF HAEMORRHOIDS
Treatments for hemorrhoids vary in their cost, risk, and effectiveness. Different cultures and individuals approach treatment differently. It is usually best, with haemorrhoids, to get by with the least treatment possible, as even after the most extensive treatments they may still return. Many times they will settle down over a matter of days without any treatment. Haemorrhoids of pregnancy usually settle after the birth of the child. Otherwise treatment is needed.
METHODS OF MANAGEMENT
1. General management
2. Medical management
-surgical
-medicinal
3. Preventive measures
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1. GENERAL MEASURES
Medical treatment of hemorrhoids is aimed initially at relieving symptoms. Measures to reduce symptoms include · Warm tub baths several times a day in plain, warm water for about 10 minutes. · Application of a haemorrhoidal cream or suppository to the affected area for a limited time. Preventing of the recurrence of hemorrhoids will require relieving the pressure and straining of constipation by maintaining the correct regular bowel habits, with proper dietary supplementation and keeping routine perianal exercises.
Dietary recommendations usually include increasing fiber and fluids in the diet. Eating the right amount of fiber and drinking six to eight glasses of fluid (not alcohol) result in softer, bulkier stools. A softer stool makes emptying the bowels easier and lessens the pressure on hemorrhoids caused by straining. Eliminating straining also helps prevent the hemorrhoids from protruding. Good sources of fiber are fruits, vegetables, and whole grains. Excessive consumption of milk and milk products should also be avoided to make the stool less acidic. In addition, doctors may suggest a bulk stool softener or a fiber supplement such as psyllium or methylcellulose.
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Haemorrhoids are rarely dangerous or life threatening. In most cases symptoms will disappear within a few days but in some cases treatment may be needed to get rid of them. Treatment cannot guarantee a complete cure, although you can help preventing haemorrhoids from returning by eating a high-fibre diet and drinking plenty of fluids.
2. MEDICAL TREATMENT
In some cases, hemorrhoids must be treated endoscopically or surgically. These methods are used to shrink and destroy the haemorrhoidal tissue. The doctor will perform the procedure during an office or hospital visit. A number of methods may be used to remove or reduce the size of hemorrhoids.
Painless Techniques for the Treatment of Hemorrhoids
Major surgery for hemorrhoids can generally be avoided in favor of more sophisticated and often painless methods of treatment. Non-surgical methods of treatment are available to most patients as a viable alternative to a permanent hemorrhoid cure.
Sclerotherapy (injection therapy):
Sclerosant or hardening agent is injected into hemorrhoids. This causes the vein walls to collapse and the hemorrhoids to shrivel up. To shrink the hemorrhoid and its blood vessels, medicine is injected into the mucous membrane near the hemorrhoid. This method is reserved for the smallest of hemorrhoids. The most commonly used scleroscent is 5% phenol in almond or arachis oil with 40 mg of menthol to make 30 ml solution (Albright solution).
Haemorrhoidolysis/ Galvanic Electrotherapy Therapeutic galvanic waves applied directly to the hemorrhoid produce a chemical reaction that shrinks and dissolves haemorrhoidal tissue. This technique is most effective when it is used on internal hemorrhoids. Therapeutic galvanic waves applied directly to the hemorrhoid, produces a chemical reaction that shrinks and dissolves haemorrhoidal tissue. This technique is most effective when it is used on internal hemorrhoids.
Bipolar Coagulation Bipolar electrotherapy is applied for a directed coagulation effect of the mucous membrane near the hemorrhoid. Specialized Bipolar Circumactive Probes (BICAP) are effective for the treatment of bleeding internal hemorrhoids. Laser, infrared beam, or electricity is used to cauterize the affected tissues. Lasers are now much less popular.
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Photocoagulation A device called a photocoagulator focuses infrared light into a fine point at the end of a probe, which spot welds the hemorrhoid in place. This is used for hemorrhoids that are actively bleeding.
Rubber band Ligation
This is a common procedure and involves rubber bands being placed around the base of the haemorrhoid to cut off its blood supply, causing it to drop off painlessly. The tissue at the base of the haemorrhoid heals with some scar tissue. It is a successful operation and can be performed quickly and easily.
A special instrument fits a small rubber band over part of the hemorrhoid. A tight rubber band stops the blood flow into the pinched-off portion, which falls off in about a week. This technique is widely used for hemorrhoids protruding into the anal canal. In this procedure, the haemorrhoidal tissue is pulled into a double sleeved cylinder to allow the placement of latex/rubber bands around the tissue. (Fig. 1) Overtime, the tissue below the bands dies off and is eliminated during a bowel movement. (Fig. 2)
However, as haemorrhoids are treated one at a time, a number of treatments may be required. Banding of internal haemorrhoids is usually painless as the base of the haemorrhoid originates above the anus opening - in the very last part of the gut where the gut lining is not sensitive to pain. Up to three haemorrhoids may be treated at one time using this method. A small number of people have complications following banding such as bleeding, urinary problems, or infection or ulcers forming at the site of a treated haemorrhoid. Rubber band Ligation is most effective when combined with a Sclerotherapy injection for prolapse. 100
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Haemorrhoidal Arterial Ligation (H.A.L.)
H.A.L is performed using a modified proctoscope in conjunction with a Doppler ultrasound flow meter. A needle and thread is passed beneath the artery, and a knot is externally tied, to stop the blood flow to the hemorrhoid.
Doppler Guided Haemorrhoidal Artery Ligation
The only evidence based surgery for all grades of hemorrhoids. It does not involve cutting tissues or even a stay at the hospital; patients are usually back to work on the same day. Best treatment for bleeding piles, as the bleeding stops immediately
Cryosurgery
A frozen tip of a cryoprobe is used to destroy haemorrhoidal tissues by spraying it with a very cold liquid to make it shrink. Rarely used anymore because of side effects
Super Freezing A cryogenic device uses liquid nitrogen to super freeze the hemorrhoid. This causes the affected tissue to slough off, so that new healthy tissue can grow in its place. This technique is most effective when it is used on external hemorrhoids
Surgical treatment of haemorrhoids
In many cases haemorrhoidal disease can be treated by dietary modifications, topical medications and soaking in warm water, which temporarily reduce symptoms of pain and swelling. Additionally, painless non-surgical methods of treatment are available to most of our patients as a viable alternative to a permanent hemorrhoid cure.
In a certain percentage of cases, however, surgical procedures are necessary to provide satisfactory, long term relief. The minor true surgical procedure to clamp and remove the haemorrhoid is called Haemorrhoidectomy. The indications for this are third degree haemorrhoids, failure of nonoperative treatment of 2nd degree haemorrhoids, fibrosed haemorrhoids and intero-external haemorrhoids when the external haemorrhoid is well defined.
In cases involving a greater degree of prolapse, a variety of operative techniques are employed to address the problem.
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Milligan-Morgan Technique Developed in the United Kingdom by Drs. Milligan and Morgan, in 1937. The three major haemorrhoidal vessels are excised. In order to avoid stenosis, three pear- shaped incisions are left open, separated by bridges of skin and mucosa. This technique is the most popular method, and is considered the gold standard by which most other surgical haemorrhoidectomy techniques are compared.
Ferguson Technique Developed in the United States by Dr. Ferguson, in 1952. This is a modification of the Milligan-Morgan technique (above), whereby the incisions are totally or partially closed with absorbable running suture.
A retractor is used to expose the haemorrhoidal tissue, which is then removed surgically. The remaining tissue is either sutured or is sealed through the coagulation effects of a surgical device. Due to the high rate of suture breakage at bowel movement, the Ferguson technique brings no advantages in terms of wound healing (5-6 weeks), pain, or postoperative morbidity. Conventional haemorrhoidectomy can be performed as a day-case procedure. But due to poor post-operative care in the community and high level of pain experienced after the procedure, an in-patient stay is often required (average of 3 days)
Stapled Haemorrhoidectomy
Also known as Procedure for Prolapse & Hemorrhoids (PPH), Stapled Haemorrhoidopexy , and Circumferential Mucosectomy. It is designed to resect soft tissue proximal to the dentate line, which disrupts the blood flow to the hemorrhoids. It is generally less painful than complete removal of hemorrhoids and also allows for faster recovery times. It's meant for hemorrhoids that fall out or bleed and is not helpful for painful outside conditions. 102
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PPH is a technique developed in the early 90's that reduces the prolapse of haemorrhoidal tissue by excising a band of the prolapsed anal mucosa membrane with the use of a circular stapling device. In PPH, the prolapsed tissue is pulled into a device that allows the excess tissue to be removed while the remaining haemorrhoidal tissue is stapled. This restores the haemorrhoidal tissue back to its original anatomical position.
The introduction of the Circular Anal Dilator causes the reduction of the prolapse of the anal skin and parts of the anal mucous membrane. After removing the obturator, the prolapsed mucous membrane falls into the lumen of the dilator. The Purse-String Suture Anoscope is then introduced through the dilator. This anoscope will push the mucous prolapse back against the rectal wall along a 270° circumference, while the mucous membrane that protrudes through the anoscope window can be easily contained in a suture that includes only the mucous membrane. By rotating the anoscope, it will be possible to complete a purse- string suture around the entire anal circumference. The Haemorrhoidal Circular Stapler is opened to its maximum position. Its head is introduced and positioned proximal to the purse-string, which is then tied with a closing knot.
The ends of the suture are knotted externally. Then the entire casing of the stapling device is introduced into the anal canal. During the introduction, it is advisable to partially tighten the stapler. With moderate traction on the purse-string; a simple maneuver draws the prolapsed mucous membrane into the casing of the circular stapling device. The instrument is then tightened and fired to staple the prolapse. Keeping the stapling device in the closed position for approximately 30 seconds before firing and approximately 20 seconds after firing acts as a tamponade, which may help to promote hemostasis. Firing the stapler releases a double staggered row of titanium staples through the tissue. A circular knife excises the redundant tissue. A circumferential column of mucosa is removed from the upper anal canal. Finally, the staple line is examined using the anoscope. If bleeding from the staple line occurs, additional absorbable sutures may be placed.
The Benefits of PPH over other Surgical Procedures 1) Patients experience less pain as compared to conventional techniques. 2) Patients experience a quicker return to normal activities compared to those treated with conventional techniques. 3) Mean inpatient stay was lower compared to patients treated with conventional techniques.
The Risks of PPH Although rare, there are risks that accompany PPH
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1) If too much muscle tissue is drawn into the device, it can result in damage to the rectal wall.
2) The internal muscles of the sphincter may stretch, resulting in short-term or long-term dysfunction.
3) As with other surgical treatments for haemorrhoids, cases of pelvic sepsis have been reported following stapled Haemorrhoidectomy
4) PPH may be unsuccessful in patients with large confluent hemorrhoids. Gaining access to the anal canal can be difficult and the tissue may by too bulky to be incorporated into the housing of the stapling device
5) Persistent pain and fecal urgency after stapled haemorrhoidectomy, although rare, has been reported
6) Stapling of hemorrhoids is associated with a higher risk of recurrence and prolapse than conventional hemorrhoid removal surgery
Harmonic Scalpel Haemorrhoidectomy
The Harmonic Scalpel uses ultrasonic technology, the unique energy form that allows both cutting and coagulation of haemorrhoidal tissue at the precise point of application, resulting in minimal lateral thermal tissue damage. Because the Harmonic Scalpel uses ultrasound, there is less smoke than is generated by both lasers and electrosurgical instruments. The Harmonic Scalpel cuts and coagulates by using lower temperatures than those used by electro surgery or lasers. Harmonic Scalpel technology controls bleeding by coaptive coagulation at low temperatures ranging from 50ºC to 100ºC: vessels are coapted (tamponaded) and sealed by a protein coagulum. Coagulation occurs by means of protein denaturation when the blade, vibrating at 55,500 Hz, couples with protein, denaturing it to form a coagulum that seals small coapted vessels. When the effect is prolonged, secondary heat is produced that seals larger vessels. Because ultrasound is the basis for Harmonic Scalpel technology, no electrical energy is conducted to the patient.
By contrast, electro surgery coagulates by burning (obliterative coagulation) at temperatures higher than 150ºC. Blood and tissue are desiccated and oxidized (charred), forming eschar that covers and seals the bleeding area. The reduced postoperative pain after Harmonic Scalpel haemorrhoidectomy compared with electrocautery controls, likely results from the avoidance of lateral thermal injury.
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The protein coagulum caused by the application of the Harmonic Scalpel is superior at sealing off large bleeding vessels during surgery. It has been my experience that this method is useful on large hemorrhoids that may bleed during surgery, thus minimizing blood loss and reducing the time needed for surgery.
Laser Surgery for Hemorrhoids
Laser is an effective, simple and harmless clinical procedure used for the treatment of hemorrhoids, as an alternative to medical therapy or surgery. Skilled surgeons use laser light with pinpoint accuracy. The unwanted hemorrhoid is simply vaporized or excised. The infinitely small laser beam allows for unequaled precision and accuracy, and usually rapid, unimpaired healing. The result is less discomfort, less medication, and faster healing. A hospital stay is generally not required. The laser is inherently therapeutic, sealing off nerves and tiny blood vessels with an invisible light. By sealing superficial nerve endings patients have a minimum of postoperative discomfort. With the closing of tiny blood vessels, your proctologist is able to operate in a controlled and bloodless environment. Carbon dioxide (CO2) laser Haemorrhoidectomy is feasible and safe provided it is used with care. It is associated with a reduced requirement for post-operative analgesia. The CO2 laser caused no significant alteration in anorectal physiology. It is a simple, rapid, and remarkably effective procedure. The doctors report that the procedure is significantly shorter with the Contact Laser technique, taking approximately 20 minutes for one large hemorrhoid and about 45 minutes for three. Following cold knife, electrocautery, or non-contact laser Haemorrhoidectomy, patients typically remain in the hospital for 3-5 days and leave in considerable discomfort. Following Contact Laser Haemorrhoidectomy, the typical patient will return home the same day, by 3 or 4 days they are moving their bowels without undue pain or difficulty, and they can return to their normal routine by 7-10 days post-operatively. There is less tissue damage and muscle stimulation than with other methods, the laser seals lymphatics so that there is markedly less edema, and there is some belief that the laser energy may also seal nerve endings.
Atomizing Hemorrhoids A new technique to remove hemorrhoids is called atomizing. The Atomizer™ is a medical device that was developed specifically to atomize tissue. The term "atomizing hemorrhoids" was coined because the hemorrhoids are actually reduced to minute particles into a fine mist or spray, which is immediately vacuumed away. An innovative waveform of electrical current and a specialized electrical probe, the Atomizer Wand™, was created for this purpose (patent pending).
With a wave of the Atomizer Wand, the hemorrhoids are simply excised or vaporized one or more cell layers at a time. The hemorrhoids are essentially disintegrated into an aerosol of carbon and water molecules. As a result, the surgeon operates with minimal
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bleeding, and gets better homeostasis than with traditional electrosurgical techniques. With the Atomizer, the patient gets better postoperative results, and fewer anal tags than with traditional operative techniques.
In the United States, the Ferguson Haemorrhoidectomy is considered the gold standard by which most other surgical Haemorrhoidectomy techniques are compared. A clinical study at the Hemorrhoid Care Medical Clinic, of thirty patients, compared the traditional Ferguson Haemorrhoidectomy with the CO2 laser Haemorrhoidectomy, and the Atomizer Haemorrhoidectomy, and revealed the following:
Haemorrhoidectomy: Atomizing vs. the CO2 laser.
The results of atomizing hemorrhoids are similar to that of lasering hemorrhoids, except that there is less bleeding using the Atomizer and the Atomizer cost less. In both procedures, it is noted that there is less discomfort, less medication, less constipation, less urinary retention, and a hospital stay is generally not required. Complications using the Atomizer are rare, and excellent results are typical.
RUBBER BAND LIGATION
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HARMONIC SCALPEL HARMONIC SCALPEL
HAEMORRHOIDECTOMY APPLIED TO TISSUE
STAPLED HAEMORRHOIDECTOMY
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Complications of Hemorrhoid Surgery
Early Complications Include:
1) Severe postoperative pain, lasting 2-3 weeks can occur. This is mainly due to incisions of the anus, and ligation of the vascular pedicles
2) Wound infections are uncommon after hemorrhoid surgery. Abscess occurs in less than 1% of cases. Severe necrotizing infections are rare.
3) Postoperative bleeding.
4) Swelling of the skin bridges.
5) Major short-term incontinence
6) Difficult urination. Possibly secondary to occult urinary retention, urinary tract infection develops in approximately 5% of patients after anorectal surgery. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study).
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3) Recurrence. 4) Anal fissure
5) Minor incontinence 6) Fecal impaction after a Haemorrhoidectomy is associated with postoperative pain and narcotic use. Most surgeons recommend stimulant laxatives, or stool softeners to prevent this problem. Removal of the impaction under anesthesia may be required . 7) Delayed hemorrhage, probably due to sloughing of the vascular pedicle, develops in 1 to 2 percent of patients. It usually occurs 7 to 16 days postoperatively. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for one or more stitches.
3. PREVENTION
Dietary measures
Drinking more fluids (more than 2 lit / day) which soften faeces. Most sorts of drink will do, but alcoholic drinks can be dehydrating and may not be so good.
Eating more dietary fiber (more than 20-30 gm / day). Foods rich in fibre include fruit, vegetables and whole grains. Fibre helps to soften stools making their passage easier.
Avoid long use of very spicy foods, too much coffee or black tea
Toileting.
Go to the toilet as soon as possible after feeling the need. Some people suppress this feeling and plan to go to the toilet later. This may result in bigger and harder faeces forming which are then more difficult to pass.
Do not strain on the toilet. Haemorrhoids may cause a feeling of 'fullness' in the rectum and it is tempting to strain at the end to try and empty the rectum further. Resist this.
Do not spend too long on the toilet which may encourage you to strain. (For example, do not read whilst on the toilet.)
Practicing better posture for defaecation and reducing bowel movement strain and time.
Straining can be lessened by defecating in a standing position, knees slightly bent. This position seems to use the muscles of the abdomen to expel feces preventing a strain on the anus.
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Proper hygiene
Fluids emitted by the intestinal tract may contain irritants that may increase the fissures associated with hemorrhoids. So washing the anus with cool water and soap may reduce the swelling and increase blood supply for quicker healing and may remove irritating fluid.
Exercise
Exercise regularly- swim, jog, walk or do gymnastics to reinforce pelvic region and to balance the weight it has to carry.
Squeeze firmly the sphincter muscle as if to contain bowel movement. Count up to ten and then relax. Repeat the exercise 30 times in a row, twice a day.
Even after the haemorrhoids have disappeared, exercise is continued every day for ten minutes, sitting down or standing up
Miscellaneous
Wearing tight clothing and underwear will also contribute to irritation and poor muscle tone in the region and promote hemorrhoid development. Some sufferers report a more comfortable experience without underwear or wearing only very lightweight panties, etc.
Avoiding sitting or standing for long periods.
Avoid becoming overweight, and lose weight if you are.
MEDICINAL TREATMENT
ALLOPATHIC MEDICATION
In modern medicine, Haemorrhoids are considered as surgical diseases. Even then, they try to alleviate it by means of medication fruitlessly. Allopathic medication treats a condition through antagonistic means, to stop the disease process. Their local treatment usually rests on the concept that use of anti inflammatory, anti pruritic and anti haemorrhagic will reduce the sufferings of the patient with piles. Hydrocortisone creams and suppositories are the cornerstone of conservative medical treatment in proctology. By interfering with the body’s natural immune response, this medicine helps to reduce the inflammation of haemorrhoids, but cannot cure them.
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Miscellaneous over the counter medications are used with varying degrees of success. They contain, in different proportions an assortment of anaesthetics, astringents, anti- inflammatory agents and emollients.
AYURVEDIC MEDICATION
Based on the aetiology of tri-dhoshas concept, their mode of treatment is to rectify this through the diet and drugs. Constitutional peculiarities of a person are also attributed to the preponderance of or otherwise of the different dhoshas in him even at the time of conception. Some may be with a harmony and equilibrium of them but some with vatha predominance, some with pitha predominance and some with kabha predominance.
They approach each case by considering the history of disease and physical examination to see what dhosha is deranged. Over all examination of the body in which hair, nail, colour and texture of skin, the built of body, height of patient, his speech, habits, sleep and dreams all are recorded. They dispense medicine as powders, solutions, decoctions, fermented liquids, pills, medicated oils, ghee etc. These remedies act on the body through the influence of Rasa (taste), vipaka (post-digestive taste), virya (potency) and prabhava (special action.). Every drug and diet is studied on these characters.
Haemorrhoids is also treated by giving arishtoms, choornams, and kashayas (medicated liquids and powders). The commonly used ones are chiruvilluadi and abhayarishtom. Another commonly employed method is kshara sutra i.e. Medicated threads.
Herbal Medication An herbal remedy is made from a medicinal plant or plants and used to prevent and treat diseases and ailments or to promote health and healing. Commonly used ones in haemorrhoids are –
Barberry (Berberis Aristata) is a blood purifier that has also been used for piles. The unique qualities of berberine-rich plants lie in their ability to promote healthy intestinal microbial balance and normal liver and gallbladder function.
Butcher's Broom (Ruscus Aculeatus) is used to treat varicose veins and hemorrhoids. The vein-narrowing qualities of butcher's broom have been found to relieve discomfort associated with varicose veins and other circulatory conditions.
Horse Chestnut (Aesculus Hippocastanum) extract standardized for aescin or escin, seems to increase the strength and tone of the veins in particular. It has astringent and anti-inflammatory properties. It may be used internally to aid the body in the treatment of phlebitis, varicose veins, and hemorrhoids. Externally it may be used to treat the same conditions as well as for leg ulcers. 111
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Neem (Azadirachta Indica, Margosa). In the Ayurvedic tradition, neem is recommended for the treatment of hemorrhoids. It has been shown to have anti-bacterial, anti-inflammatory and pain-relieving properties. Neem helps to prevent hemorrhoids by promoting the elimination of waste, and avoiding constipation. Neem extract applied topically to external hemorrhoids is soothing, and helps control bleeding and itching.
Psyllium is a bulk laxative and demulcent used for the short-term treatment of constipation. It is also used to treat people with irritable bowel syndrome, diverticular disease, and hemorrhoids and to lower cholesterol in people with high cholesterol.
Slippery Elm (Ulmus fulva) softens and soothes internal or external inflamed bodily tissues.
White Oak Bark (Quercus Alba). Popular for its astringent qualities, White Oak Bark encourages tissue proteins to tighten, thus strengthening vascular walls. The oak tannin binds liquids, absorbs toxins, and soothes inflamed tissues. The inhabitation of intestinal secretions may also help to resolve diarrhea.
Witch Hazel (Hammamelis viriniana) is a natural astringent used to reduce swelling and inflammation. It is effective in stopping the flow of blood, and in reducing secretions.
HOMOEPATHIC MANAGEMENT
The Homoeopathic system of medicine sprouted from the great Hahnemann’s impeccable observation, infallible interpretation, rational explanation and scientific construction of simple unknown principle of nature’s law of cure- similia similibus curentur. In this noble and lofty system, diseases are treated according to symptom similarity with single medicine in minute dose which results in rapid, gentle and permanent cure.
The very foundation of Homoeopathic practice considers man not only as an individual, but as a complete unit in himself, of which all parts comprise a well balanced whole. Homoeopathy, therefore does not consider any one part as being ill, but considers the manifestation of illness in one part in its relation to the whole man.
Disease is considered as the dynamic derangement of vital force in the interior of man and it is expressed outwardly as signs and symptoms perceptible through our senses. Through this dynamic derangement, the man is affected in totum which rationally demands a constitutional management for the extirpation of the illness in its entirely leading to a permanent restoration of health which inevitably wards off its recurrence and transference to
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the progeny and this can be achieved only through the symptomatic indivilistic antimiasmatic constitutional treatment administered by homoeopathic system.
In Homoeopathy Haemorrhoids are treated as not local but as derangement in the dynamic vital force that are expressed out through signs and symptoms of bleeding, pain, itching and prolapse and are corrected only by means of dynamic medicines, which are capable of producing artificial similar diseases in healthy individuals, in a safe, gentle and effective manner.
Homoeopathy considers not only the medicinal management but the general management of the disease also. The general management includes diet and regimens that have to be followed in chronic diseases which are well explained by Dr. Hahnemann in his works.
Besides the diet that interferes with development of Haemorrhoids, Homoeopath has to consider some additional precautions regarding diet and regimen concerning the medicine as per Hahnemann's directions.
“Considering the minuteness of the doses necessary and proper in Homoeopathic treatment, we can easily understand that during the treatment everything must be removed from the diet and regimen which can have any medicinal action, in order that the small dose may not be overwhelmed and extinguished or disturbed by any foreign medicinal irritant” (§259, Organon Of Medicine 5th Edition). “The softest tones of a distant flute that in the still midnight hours would inspire a tender heart with exalted feelings and dissolve it in religious ecstasy, are inaudible and powerless amid discordant cries and the noise of day” (Foot note 1 of §259, Organon Of Medicine 5th Edition).
“Hence the careful investigation into such obstacles to cure is so much the more necessary in the case of patients affected by chronic diseases, as their diseases are usually aggravated by such noxious influences and other disease-causing errors in the diet and regimen, which often pass unnoticed” (§260, Organon Of Medicine 5th Edition).
“The most appropriate regimen during the employment of medicine in chronic diseases consists in the removal of such obstacles to recovery, and in supplying where necessary the reverse: innocent moral and intellectual recreation, active exercise in the open air in almost all kinds of weather (daily walks, slight manual labor), suitable, nutritious, unmedicinal food and drink, etc.” (§261, Organon Of Medicine 5th Edition).
Regarding the medicinal management, rapid cure might be obtained under three conditions. “Firstly, if the medicine selected with the utmost care was perfectly homoeopathic; secondly, if it was given in the minutest dose, so as to produce the least possible 113
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excitation of the vital force, and yet sufficient to effect the necessary change in it; and thirdly, if this minutest yet powerful dose of the best selected medicine be repeated at suitable intervals, which experience shall have pronounced to be the best adapted for accelerating the cure to the utmost extent, yet without the vital force, which it is sought to influence to the production of a similar medicinal disease, being able to feel itself excited and roused to adverse reactions.” (§246, Organon of Medicine 5th Edition).
1) Medicine: No specific is there in Homoeopathy. Each medicine acts by virtue of its individualistic property as individualization is the cardinal principle of Homoeopathy both in disease, patient and in medicine. But repertory reveals a group of medicines which have more predominance in rectal area with the symptoms of bleeding, itching, prolapse, mucus discharge, pain and constipation. They are discussed under the section repertorial representation.
2) Dose: Apart from selecting the most similar homoeopathic remedy possible, a homoeopathic physician has to be aware of certain other vital facts too, which include right dose and potency of the selected medicine.
According to Hahnemann regarding the dose, “The suitableness of a medicine for any given case of disease does not depend on its accurate Homœopathic selection alone, but likewise on the proper size, or rather smallness, of the dose. If we give too strong a dose of a medicine which may have been even quite Homœopathically chosen for the morbid state before us, it must, notwithstanding the inherent beneficial character of its nature, prove injurious by its mere magnitude, and by the unnecessary, too strong impression which, by virtue of its homoeopathic similarity of action, it makes upon the vital force which it attacks and, through the vital force, upon those parts of the organism which are the most sensitive, and are already most affected by the natural disease.” (§275, Organon Of Medicine 5th Edition)
“For this reason, a medicine, even though it may be Homœopathically suited to the case of disease, does harm in every dose that is too large, the more harm the larger the dose, and by the magnitude of the dose it does more harm the greater its Homœopathicity and the higher the potency selected, and it does much more injury than any equally large dose of a medicine that is unhomœopathic, and in no respect adapted (allopathic) to the morbid state; for in the former case the so-called Homœopathic aggravation, the very analogous medicinal disease produced by the vital force stirred up by the excessively large dose of medicine, in the parts of the organism that are most suffering and most irritated by the original disease - which medicinal disease, had it been of appropriate intensity, would have gently effected a cure - rises to an injurious height; the patient, to be sure, no longer suffers from the original disease, for that has been Homœopathically eradicated, but he suffers all the more from the excessive medicinal disease and from useless exhaustion of his strength.” (§276, Organon Of Medicine 5th Edition)
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According to him, pure experiment, careful observation and accurate experience can alone determine the degree of minuteness necessary to effect the best cure in a given case (§278, Organon Of Medicine 5th Edition).
Repetition of doses - Homoeopathy also forbids frequent repetition of doses unnecessarily. The only axiom for repetition is to repeat when the original symptoms reappear or when improvement ceases.
To quote Hahnemann "It is a fundamental rule in the treatment of chronic diseases: To let the action of the remedy, selected in a mode homoeopathically appropriate to the case of disease, come to an undisturbed conclusion, so long as it visibly advances the cure, and while improvement still perceptibly progresses. This method forbids any new prescription as well as the immediate repetition of the same remedy.”
3) Potency: In general it may be stated that any curable diseases may be cured by any potency, when the indicated remedy is administered; but that the cure may be much accelerated by selecting the potency or dose appropriate to the individual case. Sc191.This selection depends on-the susceptibility of patient, the seat of disease, the nature and intensity of disease, stage and duration of the disease and the previous treatment of the disease.
“Assuming that there is a difference in the action of the various doses of medicines, and that a series of potencies or preparations of the different medicines has been available for use; it follows that the entire series should be open to every practitioner, and that each man should be competent, willing and ready to use any potency or preparation of the remedy indicated in a given case, without prejudice. If he confines himself to one or two potencies, be they low, medium, or high, he is limiting his own usefulness and depriving his patient of valuable means of relief and cure” 44.sc184
4) Single remedy: “It is useless to apply multiplicity of means where simplicity will accomplish the end.”
"In no case, it is requisite to administer more than one single, simple medicinal substance at one time." (§272, Organon Of Medicine 5th Edition).
“The use of single remedy is obviously a necessary corollary of the rule: as the drug is proved so it must be administered, if it is a true SIMILE”.
To conclude with, let us remember the words of our master, “The physician can, indeed, make no worse mistake than first, to consider as too small the doses
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which I (forced by experience) have reduced after manifold trials and which are indicated with every antipsoric remedy and secondly, the wrong choice of a remedy, and thirdly, the hastiness which does not allow each dose to act its full time.”
MIASMATIC ANALYSIS OF RECTAL SYMPTOMS
In Aphorism 5 (Organon of Medicine, 5th edn ), Hahnemann says, ‘‘Useful to the physician in assisting him to cure are the particulars of the most probable exciting cause of the acute disease, as also the most significant points in the whole history of the chronic disease, to enable him to discover its fundamental cause, which is generally due to a chronic miasm. In these investigations, the ascertainable physical constitution of the patient (especially when the disease is chronic), his mode of living and habits, his social and domestic relations, his age, sexual function, etc are taken into consideration.’’
In Aphorism 80 (Organon of Medicine,5th edn ), Hahnemann also says , ‘‘Incalculably greater and more important than the two chronic miasms just named, however, is the chronic miasm of Psora, which whilst those reveal their specific internal dyscrasia, the one by the venereal chancre, the other by the cauliflower like growths, does also, after the completion of the internal infection of the whole organism; announce by a peculiar cutaneous eruption, sometimes consisting only of a few vesicles accompanied by intolerable voluptuous tickling itching (and a peculiar odor), the monstrous internal chronic miasm- the Psora, the Psora is the only real fundamental cause and producer of all the other numerous, I may say innumerable forms of disease which under the names of nervous debility , hysteria, hypochondriasis, mania, melancholia, imbecility ,madness ,epilepsy, and convulsions of all sorts, softening of bones (rachitis), scoliosis, kyphosis, caries, cancer, fungus, nematodes, neoplasms, gout, haemorrhoids , jaundice, cyanosis, dropsy, amenorrhoea, haemorrhage from the stomach, nose, lungs, bladder and womb, of asthma and ulceration of lungs ,of impotence and barreness, of megrim, deafness, cataract, amaurosis, urinary calculus, paralysis, defects of the senses and pains of thousand kinds etc, figure in systematic works on pathology as peculiar, independent diseases. The discovery of the chronic miasms by Hahnemann was a death blow to the erroneous conceptions of the etiology of disease, in his day, and it is none the less true in our day, although a century of years lies between, and an army of thinkers and investigators, along these lines have arisen, and many of them departed this life since Hahnemann said that Psora was the parent, or the basic element of all that is known as disease.”
Constitutional medicine means the medicine which can correct the constitutional defects-inherent and acquired. The true simillimum indicated is the antimiasmatic drug in a case. Every antimiasmatic medicine is a constitutional medicine. In order to make a constitutional prescription, every physician must know that the remedy that covers the totality of
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symptoms covers the existing miasm, which is the fundamental cause of the disease. The chronic miasms modified by the environment, constitution, previous treatment etc. result in the production of varied numerous secondary symptoms.
“The true pathognomonic symptoms of a given case are those that cover the existing active miasm.” Thus the symptoms produced by the patient should be miasmatically analyzed and cleaved. Here we find that where the function of a part is complex or multiple, the miasm often bring forth or manifest their most annoying symptoms; this is especially true in the intestinal tract. The rectal symptoms are cleaved into its corresponding miasms.
KEY PSORA SYCOSIS SYPHILIS TUBERCULAR
Clinical Constipation ; Prolapse of Peri anal Bleeding rectum ; abscess; haemorrhoids and condition Morning diarrhoea fistulas ; polyp; Blind and non bleeding Dysentery and IBS(with blood); haemorrhoids IBS(with and mucus &pus) R/c fistula and abscess; Polyp Worms ;
Strictures; sinuses;
Fistulas;
Cancers are combination of the Sycotic and tubercular miasms.
A/F Diarrhoea comes Diarrhoea from Diarrhea at Least exposure to from fright, change of sea side cold brings on preparation for an weather diarrhoea. Alteration unusual event , of rectal diseases bad news, from with heart and chest over eating affections
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Sensation Soreness in Stitching pain Burning and Sensation of portal rectum. Sore, in rectum with bursting congestion with heat bruised, pressive pulsating sensation and flushing in pain sensation &around anus
during stool
Modalities Diarrhea > by pressure, >lying on warmth, warm abdomen or drinks, hot food pressure on lower part Concomitants Pain in remote Intestinal colic With With profuse cold or regions, with irritability depression warm sweat. drowsiness, &restlessness and Vomiting or retching sleepiness melancholia. may occur before &heaviness, foul Prolonged stool. May develop breath, coated constipation brain stasis. tongue, nausea and with headache loss of appetite. Great weakness after diarrhoea Stool Obstinate Jet like Lienteria ; Milk indigestion constipation, hard expulsion of Recurrent leads to curdled stool with no faeces. cough and undigested particles desire or Tenesmus with cold during in stool and during ineffectual urge slimy stool dentition dentition. Many followed by 118 ©www.similima.com diarrhoea obstinate constipation Stool may be of Poly chromatic Black and Greenish, bloody or any color. and acidic stool; extremely yellowish; ashy or Sour ,corrosive, offensive; grey due to lack of Watery &offensive grass-green With bile. Offensive, morning diarrhea color; often fish scrapings of musty or mouldy brine odor intestine and smell like rotten eggs. mucus Pain less with Always with Indigestion; Painless diarrhea, rumbling colic. with bleeding per &gurgling in Extreme rectum ;At night or abdomen Pruritis may be weakness early morning driving seen the patient out of bed Worms With irritation, With severe Convulsions All worm grinding of teeth, abdominal from worms manifestations, with crawling and colic, recurrence and creeping; itching restlessness, allergic of nose &rectum. dribbling of manifestations. Thread worms. saliva, pinworms and all twitching of other worm muscles infestations Haemorrhoids Associated with Rectal Rectal Bleeding discomfort and haemorrhoids fissures and haemorrhoids. itching; with extreme haemorrhoids Suppression or Constipation sensitiveness with putrid operation may result alternates with and pain and foetid in asthma-like lung haemorrhoids discharges. difficulties or heart troubles Ooze pus and sanious fluid. 119 ©www.similima.com MIASMATIC CLEAVAGE OF HAEMORRHOIDS Haemorrhoids are generally Syco-psoric and are classed under the Psoric miasm when they are associated with discomfort and itching. Rectal haemorrhoids with extreme sensitiveness and pain are Sycotic. Rectal fissures and haemorrhoids with putrid and foetid discharges are syphilitic. They may also ooze pus and sanious fluid. Strictures, haemorrhoids, sinuses, fistulas etc are all of Tubercular origin and are of much aggravated form when compared with Sycosis and syphilis. Bleeding haemorrhoids are of Tubercular in nature. In this miasm, haemorrhoids which are suppressed or operated on may result in asthma-like lung difficulties or heart troubles. Cancerous rectal symptoms are combinations of the Sycotic and tubercular miasms. REPERTORIAL REPRESENTATION OF HAEMORRHOIDS The symptoms under the seven international criteria for diagnosis of haemorrhoids are taken for repertorisation analysis. Analysis is done with soft ware RADAR. SL.NO. CHAPTER MAIN RUBRIC 1 Rectum Haemorrhoids 2 Rectum Haemorrhage 3 Rectum Itching 4 Rectum Prolapsus 5 Rectum Pain 6 Rectum Moisture 7 Rectum Constipation 8 Generalities Anaemia 120 ©www.similima.com The medicines come under repertorial totality after the repertorisation are sorted out according to its degree vise symptom. SL.NO MEDICINE MARKS 1 Sulphur 23/8 2 Nitric acidum 22/8 3 Graphitis 22/8 4 Calc.carbonicum 21/8 5 Nux vomica 21/8 6 Phosphorus 21/8 7 Sepia 20/8 8 Lycopodium 19/8 9 Causticum 19/8 10 Arsenicum album 18/8 11 Lachesis 18/8 12 Mercurius 18/8 REPERTORIAL ANALYSIS OF SYMPTOMS OF HEMORRHOIDS 3# MEDICINES FROM SYNTHESIS, EDITION 7.1 MAIN RUBRICS HEMORRHOIDS: Aesculus, Agaricus, Aloes, Arsenicum album, Carbo animalis, Carbo veg, Causticum, Collinsonia, Graphitis, Hamamelis, kali arsenicum, kali carbonicum, kali sulphuricum, Lachesis, Lycopodium, Muriatic acid, Nitric acidum, Nux vomica, Paeonia, Phosphorus, Pulsatilla, Sepia , Sulphur. 121 ©www.similima.com HEMORRHAGE: Aconite, Arsenicum album, Baryta carbonicum, Cactus, Calcarea carbonica, Collinsonia, Crotalus horridus, Hamamelis, Lachesis, Lycopodium, Natrum muriaticum, Nitric acidum, Nux vomica, Phosphorus, Psorinum, Sulphur. PAIN: Aesculus, Ammonium carbonica, Bromium, Causticum, Collinsonia, Graphitis, Ignatia, Kali carbonica, Lycopodium, Paeonia, Pulsatilla, Sulphur, Thuja MOISTURE (CATARRAH): Antimonium crudum, Carbo vegetabilis, Carbonicum sulphuricum, Causticum, Graphitis, Hepar sulphuricum, Nitric acidum, Sepia, Silicea, Sulphur ITCHING: Aesculus, Agaricus, Aloes, Ammonium carbonica, Calcarea carbonica, Calcarea sulphuricum, Carbo vegetabilis, Causticum, fluoric acidum, Graphitis, Kali carbonicum, Kali sulphuricum, Lycopodium, Natrum carbonicum, Nitric acidum, Nux vomica, Pulsatilla, Sulphur. PROLAPSUS: Apis mellifica, Calcarea carbonica, Ignatia, Mercurius, Muriatic acid, Nux vomica, Podophyllum, Sepia. MATERIALS Randomly selected 30 cases of Haemorrhoids from patients registered in the special OP for piles and fistula under the department of Homoeopathic Philosophy, Government Homoeopathic Medical College, Thiruvananthapuram. The period of study was from July 2006 to January 2008. For analysis, I have taken the cases where follow-up was obtained for one year. Patients were reviewed on monthly basis for a period of 12 months. Each case was analyzed, evaluated and prescribed according to the principles of Homoeopathy. The repetition, change of potency and remedy were done according to the principle of Homoeopathy.The effect of remedy was studied on the symptomatic basis. Sample of cases include bleeding types of first, second and third degree haemorrhoids and were judged by the seven international criteria for haemorrhoids which include haemorrhage, pain, constipation, prolapse of pile mass, mucus discharge, itching and anaemia. INCLUSION CRITERIA The study was conducted in both men and women under the age group 20-60 years. Only bleeding type of first, second and third degree haemorrhoids with any of these clinical symptoms 122 ©www.similima.com such as haemorrhage, pain, constipation, prolapse of pile mass, mucus discharge, itching and anaemia were selected. EXCLUSION CRITERIA Non bleeding piles, prolapse of rectum and other conditions with similar clinical symptoms like fissure, fistula, anorectal abscess, malignancy, Chron’s disease, ulcerative colitis, polyp of rectum, diverticulitis and other diseases having rectal complaints as secondary phenomena were excluded. Other causes of pruritis ani and anaemia were also excluded. Cases which needed surgical intervention were also excluded. Cases outside the prescribed age group were also excluded. DIAGNOSTIC CRITERIA Clinical diagnosis was done by assessing the presenting signs and symptoms of seven international criteria for haemorrhoids such as bleeding, pain, difficulty in passing stool and protrusion etc. Confirmatory tests like digital rectal examination and proctoscopy were also done in each case. METHODS The study was a clinical trial. Each case was taken properly in an elaborate manner, as per the directions given by Dr. Hahnemann in aphorisms 83-104 of 5th edition of Organon of Medicine. All the symptoms including subjective and objective were considered. Separate case records were kept with detailed format for each patient and routine investigations were done according to the cases. Each case was analyzed, evaluated and repertorised according to the principles of Homoeopathy. If repertorisation was needed, it was done with the software RADAR. Remedies were selected based on individualizing constitutional totality of symptoms of each patient and not on pathological findings. Diet and regimen - The patients were directed to follow dietary restrictions according to the aetiology of haemorrhoids. Apart from this, all the patients were restrained from taking other medications, internally or externally, strong and spicy foods, coffee, tea, increased quantity of milk and milk products, condiments and other food items supposed to be of possessing medicinal value during the study period. Advised to take regular proper fibrous diet and increased adequate quantity of water. Also the use of strong smelling perfumes and deodorants were advised to avoid. Regular proper exercise is also advised. However, 100 percent restriction of diet and regimen cannot be guaranteed. Review and follow up All the cases were reviewed every monthly and assessed using the following disease criteria. Disease criteria used for assessment Haemorrhage per rectum Pain with relation to defaecation 123 ©www.similima.com Constipation Protrusion of pile mass Mucus discharge Itching of anus Anaemia. Four scores were given according to the intensity and frequency of symptoms of the above criteria: PARAMETERS 0 1 2 3 BLEEDING Nil Mild Moderate Severe (1-3times) (4-6times) (6-12or more times) Nil Mild Moderate Severe PAIN (Lasts for<1hr) (Lasts for 1- (Lasts for >2hrs) 2hrs) CONSTIPATION Nil Mild Moderate Severe (Bowel moves on (per2-3 days) (per>3days) alternate days) PROLAPSE Nil Mild Moderate Severe (Spontaneous (Manual (Irreducible) reduction) reduction) MUCUS Nil Mild Moderate Profuse DISCHARGE ITCHING Nil Mild Moderate Severe ANAEMIA Nil Mild Moderate Severe Kent’s method of evaluation of symptoms was followed. Each case was repertorised using RADAR 7.0. Utmost care was taken in selecting the Homoeopathic antimiasmatic remedy so that the totality of symptoms of both the patient and the medicine coincided in every case, thereby fulfilling the law of cure. The Homoeopathic principles of single remedy and minimum dose were strictly adhered to. Medicines were supplied from the pharmacy of Government Homoeopathic Medical College, Thiruvananthapuram. The dose was, a medicated pellet of size varying from 10-30 crushed in sugar of milk to be taken at a time. Repetition of doses was also made as per strict Hahnemannian directions given in the fifth edition of ‘Organon of Medicine’ and ‘The Chronic Diseases’. Medicines were prescribed in centesimal various potencies. Range of potencies used was from 200 - 10M. Selection of potency depended on individual factors. No mother tinctures were prescribed and also no local applications were advised. Cases that 124 ©www.similima.com responded well to the first prescription were kept on ‘saccharum lactum’ till the case showed a need for the medicine. Blank tablets were given from the beginning to the end along with other medicines and placebo powder. On every follow up visit of the patient, case was properly analyzed to find out the changes in general as well as in the disease symptoms for assessing the order of cure and disease prognosis. Physical examination was done as a routine in each visit. When these patients were encountered with some acute complaints like fever, we were able to meet the cases with the related acute remedies which matched the situation. For assessing the miasmatic nature of symptoms, J.H.Allen’s Chronic miasms- psora and pseudopsora and Miasmatic Diagnosis- practical tips with clinical comparisons by Dr. Subrata Kumar Banerjea’ were used. The data obtained from the thirty patients included in the study are sorted into different tables and graphs for evaluation of socio-demographic characteristics and effectiveness of treatment. A. Socio-demographic characteristics of the study group: · Distribution of patients according to age and sex. · Distribution of patients according to occupation · Distribution of patients according to socio-economic class · Distribution of patients according to hereditary tendency with family history of piles and other diseases · Distribution of patients according to education · Distribution of patients according to clinical presentation · Distribution of patients according to predominant miasm B. Study of characteristics for the effectiveness of treatment · Distribution of patients according to change of symptoms · Distribution of patients according to medicines used in this study · Distribution of patients according to age Age No. of cases % 20 - 30 4 13.33 31 - 40 13 43.33 41 - 50 9 30 51 - 60 4 13.33 125 ©www.similima.com age 13% 13% 20 - 30 31 - 40 41 - 50 30% 44% 51 - 60 RESULT: In my study of 30 cases it is found out on analysis that the prevalence of Haemorrhoids is more among the age group between 31and 40 i.e., 43.33%. Distribution of patients according to sex. Sex No. of cases % Male 16 53.33 Female 14 46.67 SEX-RATIO (14) , 47% (16), 53% 126 MALE FEMALE ©www.similima.com RESULT: In this study conducted, male patients constitute 53.33 %( 16) and female patients 46.67 %.( 14) Distribution of patients according to occupation Occupation No: of cases % House wife 7 23.33 Student 2 6.67 Labourer 6 20 Skilled labourer 6 20 Govt.servant 6 20 Business 3 10 25 20 15 10 5 0 No :of cases % House wife Student Labourer Skilled labourer Govt.servant Business RESULT: In this study the prevalence is found to be highest in housewives (23.33%) and next comes the labourers (20%). 127 ©www.similima.com Distribution of patients according to socio-economic class Socio economic class No : of cases % Lower 8 26.67 Middle 17 56.67 Upper 5 16.67 56.67 60 50 40 30 26.67 20 17 16.67 8 10 5 0 No : of cases % Lower Middle upper RESULT: Out of 30 patients taken, I have found out that the middle class people (56.67%) are more affected with haemorrhoids in my study. 128 ©www.similima.com Distribution of patients according to hereditary tendency with family history of piles and other diseases FAMILY HISTORY No :of cases % Piles 24 80 DM 6 20 HTN 9 30 Tb 2 6.67 Ca 5 16.67 Asthma 7 23.33 Cardiac complaints 4 13.33 Rheumatic complaints 3 10 80 60 40 20 0 No :of cases % piles DM HTN TB CA ASTHMA CARDIAC COMPLTS RHEUMATIC COMPLTS RESULT: It is proved that there is a family history of piles in 24 cases. Among other diseases, hypertension shows maximum recurrence in family. Distribution of patients according to education EDUACTION MALE FEMALE TOTAL % ILLITERATE 5 2 7 23.33 129 ©www.similima.com SCHOOL LEVEL 5 4 9 30 COLLEGE LEVEL 6 8 14 46.67 TOTAL 16 14 30 9 8 7 6 5 4 3 2 1 0 MALE FEMALE illiterate school level college level RESULT: This shows that among these 30 cases under study, male and female having college level educational status are predominantly affected with haemorrhoids. Distribution of patients according to clinical presentation PARAMETERS NO:OF CASES 3 Classical - 7 criteria 10 Confirmative -6 criteria 12 Clinical -5 criteria 4 Diagnostic -4 criteria 1 Suggestive -<4 criteria 130 ©www.similima.com 12 12 10 10 8 6 4 4 3 2 1 0 No:of cases Classical -7 criteria Confirmative -6 criteria Clinical – 5 criteria Diagnostic – 4 criteria Suggestive - <4 criteria RESULT: According to the international criteria for the diagnosis of haemorrhoids, 5 groups were named based on the presence of number of clinical features. Among them, the group covering the 5 criteria which comes under clinical diagnosis possessed the highest number of cases (12) in this study. Distribution of patients according to predominant miasm PREDOMINANT NO: OF PATIENTS % MIASM Psora 11 36.67 Sycosis 7 23.33 Syphilis 2 6.67 Tubercular 10 33.33 No of patients 10 11 131 2 7 Psora Sycosis Syphilis Tubercular ©www.similima.com RESULT: Out of 30 cases, 11 patients (36.67%) show Psoric predominance, 10 patients (33.33%) show Tubercular predominance, 7 patients show (23.33%) Sycotic predominance and 2 patients (6.67%) show Syphilitic predominance. B. Study of characteristics for the effectiveness of treatment a. Distribution of patients according to change of symptoms Symptoms No. of Cured Improved No change cases No % No % No % Bleeding 30 26 86.67 4 13.33 - - Pain 29 22 75.86 7 24.13 - - Constipation 29 21 72.41 7 24.13 1 3.45 Prolapse 25 18 72 6 24 1 4 Mucus 11 8 72.73 3 27.23 - - discharge Itching 25 21 84 4 16 - - Anaemia 9 6 66.67 2 22.22 1 11.11 RESULT: Out of 30 cases presented with bleeding, 26 cases (86.67%) were cured and 4 cases (13.33%) improved. Out of 29 cases presented with pain, 22 cases (75.86%) were cured and 7 cases (24.13%) improved. Out of 29 cases presented with constipation, 21cases (72.41%) were cured, 7cases (24.13%) improved and 1case (3.45%) remained unchanged. Out of 25 cases presented with prolapse, 18 cases (72%) were cured, 6 cases (24%) improved and1case (4%) remained unchanged. Out of 11 patients presented with mucus discharge, 8 cases (80%) were cured and 3 patients (20%) improved. Out of 25cases presented with itching, 21cases (84%) were cured and 4cases (16%) showed improvement. Out of 9 patients presented with anaemia, 6cases (66.67%) were cured, 2 cases (22.22%) improved and 1 case (11.11%) remained unchanged. 1. BLEEDING FROM RECTUM. BLEEDING PER RECTUM FX BEFORE TT FX AFTER TT 26 GRADE-0 0 132 ©www.similima.com 4 GRADE-1 2 0 GRADE-2 10 0 GRADE-3 18 30 25 20 15 NO.PERSONS 10 5 0 grade-0 grade-1 grade-2 grade-3 GRADE fx before tt fx after tt RESULT: Out of 30 cases presented with bleeding, 18 cases came under grade-3, 10 cases from grade-2 and 2 cases with grade-1. It is found that 26 cases (86.67%) were cured and 4 cases (13.33%) improved and none of them came under grade-2 and grade-3 after treatment with Homoeopathic constitutional medicines. 2. PAIN. PAIN FX BEFORE FX AFTER TT TT GRADE-0 1 23 GRADE-1 14 7 GRADE-2 12 0 133 ©www.similima.com GRADE-3 3 0 25 20 15 NO:PERSONS 10 5 0 GRADE-0 GRADE-1 GRADE-2 GRADE-3 PAIN fx before tt fx after tt RESULT: Out of 29 cases presented with pain, 14 cases came under grade-1,12 cases with grade-2, 3 cases with grade-3 and 1 was presented with grade-0 severity. I have found out that after treatment 22 cases (75.86%) were completely cured of pain and 7 cases (24.13%) improved. 3. CONSTIPATION FX FX BEFORE AFTER CONSTIPATION TT TT GRADE-0 1 21 GRADE-1 10 7 GRADE-2 14 2 5 0 134 ©www.similima.com GRADE-3 25 20 15 NO:PERSONS 10 5 0 GRADE-0 GRADE-1 GRADE-2 GRADE-3 CONSTIPATION fx before tt fx after tt RESULT: In my study, out of 29 cases presented with constipation, 4 cases were with severe constipation, 14 with moderate constipation and 10 cases with mild or grade-1 form of constipation. It is seen that 21cases (72.41%) were came out with out constipation, 7cases (24.13%) improved and 1case (3.45%) remained unchanged. 4. PROLAPSE FX FX PROLAPSE BEFORETT AFTERTT GRADE-0 5 18 GRADE-1 10 9 GRADE-2 12 2 GRADE-3 3 1 135 ©www.similima.com 18 16 14 12 10 NO:PERSONS 8 6 4 2 0 GRADE-0 GRADE-1 GRADE-2 GRADE-3 PROLAPSE fx before tt fx after tt RESULT: My study reveals that out of 25 cases presented with prolapse, 3cases were with 3rd degree prolapse, 12 cases with 2nd degree and 10 cases with 1st degree prolapse. It is found out that 18 cases (72%) were cured, 6 cases (24%) improved and1case (4%) remained unchanged. 5. MUCUS DISCHARGE FX FX MUCUS BEFORE AFTER DISCHARGE TT TT GRADE-0 19 27 GRADE-1 7 3 GRADE-2 4 0 GRADE-3 0 0 136 ©www.similima.com 30 25 20 NO:PERSON 15 S 10 5 0 GRADE-0 GRADE-1 GRADE-2 GRADE-3 MUCUS DISCHARGE fx before tt fx after tt RESULT: Out of 11 patients presented with mucus discharge, 4 patients came under moderate group and 7 came under milder variety. After treatment 8cases (80%) were cured and 3 patients (20%) improved in intensity of mucus discharge. 6. ITCHING FX FX AFTER ITCHING BEFORETT TT GRADE-0 5 26 GRADE-1 11 4 GRADE-2 14 0 GRADE-3 0 0 30 25 20 15 10 5 0 137 GRADE-0 GRADE-1 GRADE-2 GRADE-3 FX BEFORE TT FX AFTER TT ©www.similima.com RESULT: Out of 25cases presented with itching, 14 with moderate itching and 11 with mild itching. After treatment, 21cases (84%) were cured and 4cases (16%) showed improvement 7. ANAEMIA FX FX AFTER ANAEMIA BEFORETT TT GRADE-0 21 27 GRADE-1 7 2 GRADE-2 2 1 GRADE-3 0 0 RESULT: Out of 9 patients presented with anaemia, 7 persons were in mild category and 2 persons in moderate category. 6 cases (66.67%) were cured, 2 cases (22.22%) improved and 1 case (11.11%) remained unchanged after treatment. · Distribution according to the different medicines used in this study SL MEDICINE NO : OF % NO: PATIENTS 1 Alumina 1 3.33 138 ©www.similima.com 2 Arg.nitricum 1 3.33 3 Causticum 1 3.33 4 2 6.67 Calc.carb 5 1 3.33 China 6 1 3.33 Graphites 7 2 6.67 Ignatia 8 1 3.33 Lachesis 9 1 3.33 Lycopodium 10 1 3.33 Medorrhinum 11 2 6.67 Nat.mur 12 1 3.33 Nitric acid 139 ©www.similima.com 13 2 6.67 Nux.vomica 14 2 6.67 Phosphorus 15 1 3.33 Phos.acid 16 2 6.67 Pulsatilla 17 2 6.67 Sepia 18 2 6.67 Silicia 19 2 6.67 Staphysagria 20 Sulphur 2 6.67 21 Tuberculinum 1 3.33 RESULT: Out of 30 cases under study no single medicine administered is found to be more effective than the other. Each medicine effects by virtue of its constitutional similarity with the patient. To analyse statistically the difference between pre treatment observations and post treatment observations, ‘‘paired‘t’ test’’ is used. Let X1 be the value before treatment and X2 after the treatment. 140 ©www.similima.com Let the hypothesis be - H0: no difference between before and after the treatment. H1: X2 2 SL No X1 X2 d= X1- X2 d 1 14 4 10 100 2 8 1 7 49 3 12 2 10 100 4 11 1 10 100 5 9 1 8 64 6 13 5 8 64 7 6 1 5 25 8 9 2 7 49 9 10 1 9 81 10 9 1 8 64 11 10 1 9 81 12 7 1 6 36 13 9 1 8 64 14 11 2 9 81 15 6 1 5 25 16 12 5 7 49 17 6 2 4 16 141 ©www.similima.com 18 9 1 8 64 19 8 1 7 49 20 11 1 10 100 21 10 2 8 64 22 10 3 7 49 23 11 2 9 81 24 8 1 7 49 25 9 1 8 64 26 9 2 7 49 27 12 4 8 64 28 7 1 6 36 29 13 1 12 144 30 7 1 6 36 ∑d = 233 ∑ d2 = 1897 n = 30 (i.e. Total number of observations) đ = ∑ d = 233 =7.766 n 30 142 ©www.similima.com S.D = [∑ d2 - (∑d) 2] / [n-1] ½ = 1.735 n 1.735 S.D = ------= 0.317 √n 5.477 t = đ = 24.498 S.D /√n From the table, paired t value, tα at n-1 degree of freedom, i.e. t29 at 5% (0.05) level of significance = 1.699 t29 at 1% (0.01) level of significance = 2.462 Since‘t’ value obtained is much greater than the table value t29, we can reject the null hypothesis H0 (no difference before and after treatment) and accept the alternate hypothesis H1 (difference present). That is, the present mode of Constitutional treatment of Haemorrhoids is effective. The discussion that follows is exclusively based on the observation and results presented in the former section. Firstly, to discuss about the various attributes involved in this study. 1. Age incidence: Haemorrhoids are found to occur more among the age group from 31 to 40 i.e., 43.33%. 2. Sex incidence: 53.33% were males and 46.67% were females. 3. Educational status: prevalence is more in college level education. This can be considered as a reflection of the higher rate of literacy in our state 4. Occupational status: higher incidence was found to be in house wives (23.33%) and next in labourers. 5. Economic status : 56.67% in middle class group which can be attributed to higher concentration of aetiology in middle class population 143 ©www.similima.com 6. Distribution of clinical features: 100% had bleeding, 83.33% had pain and constipation, 50% had prolapse and itching and 33.33% had anaemia at the first consultation. After treatment it was found out that there was marked reduction in symptoms which showed the efficacy of management. 7. Hereditary tendency: 80% of patients showed a history of piles in family. 8. Miasmatic predominance: 36.67% showed Psoric predominance though bleeding haemorrhoids come under tubercular miasm which was 33.33% in this study. 9. Order of effective medicines: A single medicine cannot be said as much effective for haemorrhoids when compared to others, which emphasizes the significance of individualization in Homoeopathy. 10. Evaluation of change in disease criteria : a) Bleeding - Out of 30 cases ,26 cases (86.67%) were cured and 4 cases (13.33%) showed improvement b) Pain - Out of 29 cases, 22 cases (75.86%) were cured and 7 cases (24.13%) showed improvement c) Constipation - Out of 29 cases, 21cases (72.41%) were cured, 7cases (24.13%) improved and 1case (3.45%) remained unchanged. d) Prolapse - Out of 25 cases, 18 cases (72%) were cured, 6 cases (24%) improved and1case (4%) remained unchanged. e) Mucus discharge - Out of 11 patients, 8cases (72.73%) were cured and 3 patients (27.23%) showed improvement f) Itching - Out of 25cases, 21cases (84%) were cured and 4cases (16%) showed improvement. g) Anaemia - Out of 9 patients, 6 cases (66.67%) were cured, 2 cases (22.22%) improved and 1 case (11.11%) remained unchanged. From the evaluation of results obtained after the statistical analysis of the pre-treatment and post- treatment disease intensity scores, it is obvious that constitutional medicines selected on the basis of the conceptual totality of symptoms are highly effective in the management of Haemorrhoids. 144 ©www.similima.com The mental generals and physical generals should be given prime importance. The tendency to the recurrence of piles can be controlled/ eradicated by the exact simillimum. Thus it is proved that any disease, even if it is a surgical one (provided they are within the reversible limit) can be cured by the intuitive and diligent adherence to the Homoeopathic principles. Other factors observed in this study are high prevalence of Haemorrhoids is seen in age group 31-40, coming from middle class with an adequate educational status. Even though bleeding Haemorrhoids are coming under pseudopsora, my study verified its Psoric predominance of in these 30 cases. Antimiasmatic deep acting constitutional medicines like Sepia, Natrum mur, Ignatia, Phosphorus, Calc.carb, Lycopodium, Nux vomica, Sulphur, Pulsatilla, Silicea, Stapysagria etc were found to be effective for controlling both the acute attacks and also for preventing recurrence, when given after strict individualization. Many cases, which are recommended to do surgery, can be effectively treated with Homoeopathic constitutional medicine. It can also be claimed that Homoeopathy is far more cost effective when compared with expensive drugs and other procedures like cryosurgery, banding etc used in other systems of medicines. To conclude, limited reliability can only be guaranteed with such a study involving a chronic disease, with 30 cases, for period of one year follow up. A long term follow- up study will be more reliable as the disease is exhibiting recurrence. Comparative studies involving other systems of medicine can also be accomplished with better results. Many great truths have had their meteoric rise, acceptance and period of swing and sway, followed by a long period of deterioration and decline and obscurity and oblivion but never has a great truth been lost. There are always a few ardent followers who survive to hold the truth committed to them as a precious possession and cherish it until a revival dawns. This is what is witnessed in the Homoeopathic Philosophy of Dr. Samuel Hahnemann which has its mooring in the inviolable nature’s law which challenges always but seldom changes. In spite of many a pointed criticism and scurrilous remarks and scorching and demoralizing attitude and action, he went on clinging to the truth for the everlasting health and happiness of humanity. With this invincible conviction and fervent commitment, Dr. Hahnemann in the first aphorism of the Organon of Medicine declares that the "physician's high and only mission is to restore the sick to health, to cure, as it is termed". 145 ©www.similima.com In the second aphorism of the Organon of Medicine, Hahnemann gives an adequate and satisfying definition for an ideal cure:" "The highest ideal of cure is rapid, gentle and permanent restoration of the health, or removal and annihilation of the disease in its whole extent, in the shortest, most reliable and most harmless way, on easily comprehensible principles." If this is to be achieved, every physician must know what is to be cured in each and every case and it is revealed by the totality of symptoms. “The true pathognomonic symptoms of a given case are those that cover the existing active miasm.” Thus the true simillimum indicated is the antimiasmatic drug in a case. Constitutional medicine means the medicine which can correct the constitutional defects-inherent and acquired. Every antimiasmatic medicine is a constitutional medicine. BIBLIOGRAPHY 1. Allen, J.H :The Chronic Miasms- Psora and Pseudo-psora;B.Jain Publishers, Pvt Ltd; New Delhi. 2. Banerjee, P. N : Chronic Diseases; B. Jain Publishers, Pvt.Ltd; New Delhi 3. Banerjee,S.K : Miasmatic Diagnosis; B.Jain publishers, Pvt Ltd; New Delhi 4. Boenninghausen : The Lesser Writings; B. Jain publishers, Pvt Ltd; New Delhi. 5. Boericke. W. M : A Compend of The Principles of Homoeopathy; B. Jain publishers, 6. Clarke, John Henry : Homoeopathy Explained ;Reprint edition; Bain publishers, Pvt Ltd; New Delhi 7. Clarke, John Henry : Constitutional Medicine ,with special reference to the three constitutios of Dr.VonGrauvogl B.Jain publishers, Pvt Ltd; New Delhi 8. 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William and Warwick : Gray’s Anatomy,36th edition;Churchil ving stone, New york 39. Websites : www.haemorrhoid.net , www.sabiston.net Dr. Thanka.R Trivandrum. Kerala Email : [email protected] All rights reserved. (C) No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical including photocopy, recording or any information storage and retrieval system, without permission in writing from author and publisher. 148